Healthcare Provider Details

I. General information

NPI: 1982995163
Provider Name (Legal Business Name): DAVID M SCHACKOW SR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S 11TH ST
NILES MI
49120-2757
US

IV. Provider business mailing address

54874 KRISTI LN
OSCEOLA IN
46561-9237
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-6556
  • Fax: 269-687-6365
Mailing address:
  • Phone: 574-674-4217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302021153
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: