Provider Demographics
NPI:1205118643
Name:BACH, JASON D
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
Last Name:BACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G4010 FENTON RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3681
Mailing Address - Country:US
Mailing Address - Phone:810-424-0224
Mailing Address - Fax:810-424-0618
Practice Address - Street 1:G4010 FENTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3681
Practice Address - Country:US
Practice Address - Phone:810-424-0224
Practice Address - Fax:810-424-0618
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist