Provider Demographics
NPI:1972854107
Name:KLIES, LORRAINE DARLENE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:DARLENE
Last Name:KLIES
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 1:6390 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3572
Mailing Address - Country:US
Mailing Address - Phone:269-327-4508
Mailing Address - Fax:269-327-6740
Practice Address - Street 1:6390 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3572
Practice Address - Country:US
Practice Address - Phone:269-327-4508
Practice Address - Fax:269-327-6740
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist