Provider Demographics
NPI:1801809264
Name:SOMERS, CHARLES O (RPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:O
Last Name:SOMERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18176 LOST CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9094
Mailing Address - Country:US
Mailing Address - Phone:616-842-0906
Mailing Address - Fax:
Practice Address - Street 1:1900 RUDDIMAN DR
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3148
Practice Address - Country:US
Practice Address - Phone:231-744-4718
Practice Address - Fax:231-744-5574
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302020598OtherPHARMACIST LICENSE