Provider Demographics
NPI:1902568629
Name:CAMPBELL, CARISSA JEAN (PHARMD, MBA)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:JEAN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2543 WOODLAKE RD SW APT 6
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4716
Mailing Address - Country:US
Mailing Address - Phone:708-769-5007
Mailing Address - Fax:
Practice Address - Street 1:494 BUTTERNUT DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1556
Practice Address - Country:US
Practice Address - Phone:616-786-2235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist