Basic Information
| Provider Information | |||||||||
| NPI: | 1114104288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MPAMIRA | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | MUTESI | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | SUITE 107 - ONE JACKSON SQUARE | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884800 | ||||||||
| FaxNumber: | 5178411725 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | SUITE 107 - ONE JACKSON SQUARE | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884800 | ||||||||
| FaxNumber: | 5178411725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302034616 | MI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.