Provider Demographics
NPI:1881103372
Name:KILLIPS, JAQUELIN (RPH)
Entity type:Individual
Prefix:
First Name:JAQUELIN
Middle Name:
Last Name:KILLIPS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-2738
Mailing Address - Country:US
Mailing Address - Phone:906-632-0816
Mailing Address - Fax:906-632-2855
Practice Address - Street 1:12455 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9327
Practice Address - Country:US
Practice Address - Phone:906-248-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist