Provider Demographics
NPI:1700423563
Name:SIMMONS, LINDA RENEE
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RENEE
Last Name:SIMMONS
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 1:2710 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-8979
Mailing Address - Country:US
Mailing Address - Phone:574-261-7425
Mailing Address - Fax:
Practice Address - Street 1:1217 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-3448
Practice Address - Country:US
Practice Address - Phone:574-291-0666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-28
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015106A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist