MEDICARE: COSALUS HEALTH PLLC

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	5302021538	MI

General Provider Information

NPI Number	:	1003152752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSALUS HEALTH PLLC

Provider Business Mailing Address
First Line	:	3031 POPLAR CREEK DR SE
Second Line	:	SUITE 103
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5682
Country	:	US
Telephone Number	:	616-481-9073
Fax Number	:	616-975-7596

Provider Business Practice Location Address
First Line	:	3031 POPLAR CREEK DR SE
Second Line	:	SUITE 103
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5682
Country	:	US
Telephone Number	:	616-481-9073
Fax Number	:	616-975-7596

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JACK W URBEN
Credential	:	PHARM.D.
Telephone Number	:	616-481-9073

Provider Enumeration Date	:	12/28/2012
Last Update Date	:	12/28/2012

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Directions to “COSALUS HEALTH PLLC ” Practice Location

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