Healthcare Provider Details

I. General information

NPI: 1811332414
Provider Name (Legal Business Name): SHANE ROBERT KUCHARCZYK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 S LAKESHORE RD
HARBOR BEACH MI
48441-8979
US

IV. Provider business mailing address

1115 S LAKESHORE RD
HARBOR BEACH MI
48441-8979
US

V. Phone/Fax

Practice location:
  • Phone: 810-841-5910
  • Fax:
Mailing address:
  • Phone: 810-841-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302039349
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: