Provider Demographics
NPI:1669244901
Name:SOUSOUAY, CHRISTI TITI
Entity type:Individual
Prefix:
First Name:CHRISTI
Middle Name:TITI
Last Name:SOUSOUAY
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 1:137 DEPOT LN
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-7404
Mailing Address - Country:US
Mailing Address - Phone:616-594-9184
Mailing Address - Fax:
Practice Address - Street 1:132 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-6514
Practice Address - Country:US
Practice Address - Phone:616-396-2959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302415697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist