Provider Demographics
NPI:1699295113
Name:ANDERSON, JACLYN (RPH)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ANDERSON
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 1:2700 BAKER ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-737-9510
Mailing Address - Fax:
Practice Address - Street 1:2700 BAKER ST STE 3A
Practice Address - Street 2:
Practice Address - City:MUSKEGON HTS
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist