MEDICARE: DR. JACK W. URBEN PHARM.D.

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	1835P1200X	Pharmacotherapy Pharmacist	5302021538	MI

General Provider Information

NPI Number	:	1699771485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK W. URBEN PHARM.D.

Provider Business Mailing Address
First Line	:	3031 POPLAR CREEK DR SE
Second Line	:	UNIT 103
City	:	KENTWOOD
State	:	MI
Zip	:	49512-5667
Country	:	US
Telephone Number	:	616-949-9573
Fax Number	:	616-975-7596

Provider Business Practice Location Address
First Line	:	3031 POPLAR CREEK DR SE
Second Line	:	UNIT 103
City	:	KENTWOOD
State	:	MI
Zip	:	49512-5667
Country	:	US
Telephone Number	:	616-949-9573
Fax Number	:	616-975-7596

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

Provider Enumeration Date	:	06/26/2005
Last Update Date	:	07/08/2007

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