Provider Demographics
NPI:1942358080
Name:PEMBERTON, JENNIFER L (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8336 JACLYN ANN DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2908
Mailing Address - Country:US
Mailing Address - Phone:810-487-0636
Mailing Address - Fax:
Practice Address - Street 1:11830 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-1594
Practice Address - Country:US
Practice Address - Phone:810-686-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029266183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302029266OtherPHARMACIST LICENSE NUMBER