Provider Demographics
NPI:1861776627
Name:PROCIV, JESSICA (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PROCIV
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3928 N ROSEBUD DR SE
Mailing Address - Street 2:APT #8
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6938 ELM VALLEY DR STE 101
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-7438
Practice Address - Country:US
Practice Address - Phone:269-552-4167
Practice Address - Fax:269-552-4216
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020379731835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302037973OtherSTATE OF MICHIGAN BOARD OF PHARMACY