Healthcare Provider Details

I. General information

NPI: 1144862012
Provider Name (Legal Business Name): NASRIN RONAGHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2019
Last Update Date: 10/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 N CEDAR ST
KALKASKA MI
49646-8061
US

IV. Provider business mailing address

3890 VALE DR
TRAVERSE CITY MI
49686-2977
US

V. Phone/Fax

Practice location:
  • Phone: 231-258-2081
  • Fax:
Mailing address:
  • Phone: 217-549-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302044359
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: