MEDICARE: MS. JENNIFER NIEDZWIECKI 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	5302039487	MI

General Provider Information

NPI Number	:	1881029478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER NIEDZWIECKI PHARMD

Provider Business Mailing Address
First Line	:	1133 BURKE AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1207
Country	:	US
Telephone Number	:	616-250-0285
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 BURKE AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1207
Country	:	US
Telephone Number	:	616-250-0285
Fax Number	:

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

Provider Enumeration Date	:	09/13/2013
Last Update Date	:	09/13/2013

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