Healthcare Provider Details

I. General information

NPI: 1558331603
Provider Name (Legal Business Name): MARTIN ROBERT KUGEL JR RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 BALDWIN ST
JENISON MI
49428-8915
US

IV. Provider business mailing address

1909 MULLBERRY LN
JENISON MI
49428-8534
US

V. Phone/Fax

Practice location:
  • Phone: 616-457-9630
  • Fax: 616-457-1120
Mailing address:
  • Phone: 616-457-3072
  • Fax: 616-457-1120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302020397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: