Provider Demographics
NPI:1356874184
Name:ROSS, CLARICE LYNN
Entity type:Individual
Prefix:
First Name:CLARICE
Middle Name:LYNN
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 E PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1408
Mailing Address - Country:US
Mailing Address - Phone:517-736-4030
Mailing Address - Fax:
Practice Address - Street 1:800 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036
Practice Address - Country:US
Practice Address - Phone:517-278-5897
Practice Address - Fax:517-278-3319
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303001343183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician