MEDICARE: KANE CHARLES MARCINIAK PHARMD

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	183500000X	Pharmacist	5302415284	MI
2	1835P2201X	Ambulatory Care Pharmacist	5302415284	MI

General Provider Information

NPI Number	:	1639805518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANE CHARLES MARCINIAK PHARMD

Provider Business Mailing Address
First Line	:	300 LAFAYETTE AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4692
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 LAFAYETTE AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4692
Country	:	US
Telephone Number	:	616-685-6105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	03/16/2026

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