Provider Demographics
NPI:1114219490
Name:JOSEPH, JOLLY (RPH)
Entity type:Individual
Prefix:MRS
First Name:JOLLY
Middle Name:
Last Name:JOSEPH
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 1:49650 LAKEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3511
Mailing Address - Country:US
Mailing Address - Phone:586-737-7144
Mailing Address - Fax:
Practice Address - Street 1:860 N VANDYKE
Practice Address - Street 2:
Practice Address - City:ALMONT
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:810-798-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist