Provider Demographics
NPI:1952314676
Name:VIVIAN, JESSE CHARLES (RPH)
Entity Type:Individual
Prefix:PROF
First Name:JESSE
Middle Name:CHARLES
Last Name:VIVIAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:PROF
Other - First Name:JESSE
Other - Middle Name:CHARLES
Other - Last Name:VIVIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:181 CLAREMONT CIR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 CLAREMONT CIR
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9704
Practice Address - Country:US
Practice Address - Phone:517-592-3981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist