Healthcare Provider Details

I. General information

NPI: 1578583175
Provider Name (Legal Business Name): KINGSLEY PHARMACY AND COMPOUNDING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 S BROWNSON AVE
KINGSLEY MI
49649-5103
US

IV. Provider business mailing address

PO BOX 247
KINGSLEY MI
49649-0247
US

V. Phone/Fax

Practice location:
  • Phone: 231-263-7701
  • Fax: 231-263-7925
Mailing address:
  • Phone: 231-263-7701
  • Fax: 231-263-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010671
License Number StateMI

VIII. Authorized Official

Name: BRIAN REUTHER
Title or Position: PRESIDENT
Credential:
Phone: 231-263-7701