Healthcare Provider Details

I. General information

NPI: 1689128761
Provider Name (Legal Business Name): MICHAEL RUSZKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2016
Last Update Date: 08/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

899 CAMELLIA LN
WAYLAND MI
49348-8919
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone: 616-901-9286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number5302042057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: