Provider Demographics
NPI:1871022830
Name:ROTHERMAL, MARY VENETTA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:VENETTA
Last Name:ROTHERMAL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9577
Mailing Address - Country:US
Mailing Address - Phone:517-456-4150
Mailing Address - Fax:
Practice Address - Street 1:140 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-9577
Practice Address - Country:US
Practice Address - Phone:517-456-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist