MEDICARE: LORI NOEL CLEMMENS-FUNKE PHARMD

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	5302034501	MI

General Provider Information

NPI Number	:	1730172446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI NOEL CLEMMENS-FUNKE PHARMD

Provider Business Mailing Address
First Line	:	20361 PINE LAKE RD
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-8111
Country	:	US
Telephone Number	:	269-966-9185
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 NORTH AVE
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49017-3307
Country	:	US
Telephone Number	:	269-964-5852
Fax Number	:

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

Provider Enumeration Date	:	08/27/2005
Last Update Date	:	07/08/2007

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