=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457406340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEE ANN PREBOLA RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36567 GODDARD RD
-----------------------------------------------------
City | ROMULUS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48174-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-941-0755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19497 INGRAM ST
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-1589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 53020206399
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------