Provider Demographics
NPI:1902403827
Name:MCINTOSH, DONTA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DONTA
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 W CLARK RD APT N206
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9442
Mailing Address - Country:US
Mailing Address - Phone:313-461-4517
Mailing Address - Fax:
Practice Address - Street 1:632 N DIBBLE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2830
Practice Address - Country:US
Practice Address - Phone:517-323-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist