Healthcare Provider Details

I. General information

NPI: 1952314676
Provider Name (Legal Business Name): JESSE CHARLES VIVIAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JESSE CHARLES VIVIAN RPH

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 CLAREMONT CIR
BROOKLYN MI
49230-9704
US

IV. Provider business mailing address

181 CLAREMONT CIR
BROOKLYN MI
49230-9704
US

V. Phone/Fax

Practice location:
  • Phone: 517-592-3981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302022073
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: