Provider Demographics
NPI:1770170193
Name:BASS, FAWN
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:BASS
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 1:8745 HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-9104
Mailing Address - Country:US
Mailing Address - Phone:269-449-2110
Mailing Address - Fax:269-429-7578
Practice Address - Street 1:5637 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9613
Practice Address - Country:US
Practice Address - Phone:269-429-8441
Practice Address - Fax:269-429-7578
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315122181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
227434OtherNABP PERSONAL