MEDICARE: FAWN BASS

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	5315122181	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	227434	OTHER		NABP PERSONAL

General Provider Information

NPI Number	:	1770170193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAWN BASS

Provider Business Mailing Address
First Line	:	8745 HOLLYWOOD RD
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-9104
Country	:	US
Telephone Number	:	269-449-2110
Fax Number	:	269-429-7578

Provider Business Practice Location Address
First Line	:	5637 CLEVELAND AVE
Second Line	:
City	:	STEVENSVILLE
State	:	MI
Zip	:	49127-9613
Country	:	US
Telephone Number	:	269-429-8441
Fax Number	:	269-429-7578

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

Provider Enumeration Date	:	12/31/2020
Last Update Date	:	12/31/2020

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Directions to “ FAWN BASS ” Practice Location

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