Healthcare Provider Details

I. General information

NPI: 1912172909
Provider Name (Legal Business Name): MARK ANTHONY IWANIEC RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37980 ANN ARBOR RD
LIVONIA MI
48150-3431
US

IV. Provider business mailing address

37980 ANN ARBOR RD
LIVONIA MI
48150-3431
US

V. Phone/Fax

Practice location:
  • Phone: 734-464-2440
  • Fax: 734-464-0383
Mailing address:
  • Phone: 734-464-2440
  • Fax: 734-464-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302024952
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: