=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750999108
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLISON GOLOM PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2020
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 15 MILE RD
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-5353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-634-5761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 15 MILE RD
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-5353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-693-0463
-----------------------------------------------------
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 | 5302042931
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------