MEDICARE: JACLYN ANDERSON RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302026830	MI

General Provider Information

NPI Number	:	1699295113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN ANDERSON RPH

Provider Business Mailing Address
First Line	:	2700 BAKER ST STE 3A
Second Line	:
City	:	MUSKEGON HTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-9510
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BAKER ST STE 3A
Second Line	:
City	:	MUSKEGON HTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-9510
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2017
Last Update Date	:	07/21/2022

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