Healthcare Provider Details

I. General information

NPI: 1104930486
Provider Name (Legal Business Name): CELIA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W MONROE ST
BANGOR MI
49013-1330
US

IV. Provider business mailing address

49510 COUNTY ROAD 681 P.O.BOX 69
LAWRENCE MI
49064-9047
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-7706
  • Fax:
Mailing address:
  • Phone: 269-655-6137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: