Provider Demographics
NPI:1922729110
Name:CALLICOAT, TIFFANY SUE (PHARMD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SUE
Last Name:CALLICOAT
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 1:700 N STATE RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1130
Mailing Address - Country:US
Mailing Address - Phone:810-658-8051
Mailing Address - Fax:
Practice Address - Street 1:700 N STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1130
Practice Address - Country:US
Practice Address - Phone:810-658-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ220793778797OtherDRIVERS LICENSE