Provider Demographics
NPI:1720245731
Name:STARK, JASON PATRICK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:PATRICK
Last Name:STARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1355
Mailing Address - Country:US
Mailing Address - Phone:616-837-6219
Mailing Address - Fax:616-837-9525
Practice Address - Street 1:1151 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1355
Practice Address - Country:US
Practice Address - Phone:616-837-6219
Practice Address - Fax:616-837-9525
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist