Provider Demographics
NPI:1790426153
Name:TAYLOR, LATRESE MARIE
Entity type:Individual
Prefix:
First Name:LATRESE
Middle Name:MARIE
Last Name:TAYLOR
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 1:3890 CADIEUX RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2373
Mailing Address - Country:US
Mailing Address - Phone:313-469-3827
Mailing Address - Fax:
Practice Address - Street 1:3890 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2373
Practice Address - Country:US
Practice Address - Phone:313-469-3827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303036998183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician