Healthcare Provider Details

I. General information

NPI: 1952861460
Provider Name (Legal Business Name): MEGAN KUCEMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41460 HAGGERTY CIR S
CANTON MI
48188-2227
US

IV. Provider business mailing address

41460 HAGGERTY CIR S
CANTON MI
48188-2227
US

V. Phone/Fax

Practice location:
  • Phone: 888-282-5166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302042775
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: