Provider Demographics
NPI:1063122596
Name:LEPORE, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LEPORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16972 TYSMAN WAY APT 301
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8070
Mailing Address - Country:US
Mailing Address - Phone:705-943-2361
Mailing Address - Fax:
Practice Address - Street 1:1045 ROBBINS RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2646
Practice Address - Country:US
Practice Address - Phone:616-844-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist