Healthcare Provider Details

I. General information

NPI: 1578140141
Provider Name (Legal Business Name): MARY BUTLEVICS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 TORIAN CT SE
ADA MI
49301-8335
US

IV. Provider business mailing address

3035 TORIAN CT SE
ADA MI
49301-8335
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-4474
  • Fax:
Mailing address:
  • Phone: 616-920-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number5302027548
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: