Provider Demographics
NPI:1255425674
Name:KLUCK, ANN PATRICE (PHARMACIST)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:PATRICE
Last Name:KLUCK
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2866 TURTLECREEK DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6333
Mailing Address - Country:US
Mailing Address - Phone:517-337-8336
Mailing Address - Fax:517-336-5638
Practice Address - Street 1:1525 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1387
Practice Address - Country:US
Practice Address - Phone:517-336-5603
Practice Address - Fax:517-336-5638
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302024174OtherMI LICENSE NUMBER