Provider Demographics
NPI:1205151297
Name:LASSILA, JAY ERIC (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ERIC
Last Name:LASSILA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-5304
Mailing Address - Country:US
Mailing Address - Phone:906-370-9750
Mailing Address - Fax:
Practice Address - Street 1:236 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-5304
Practice Address - Country:US
Practice Address - Phone:906-370-9750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035380183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302035380OtherPHARMACY LICENSE