Basic Information
| Provider Information | |||||||||
| NPI: | 1427154947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MCGOUGH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6070 PINE ISLAND DR NE | ||||||||
| Address2: | |||||||||
| City: | COMSTOCK PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493219541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167857068 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3019 COIT AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495053376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163659575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302411289 | MI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.