Healthcare Provider Details

I. General information

NPI: 1952934069
Provider Name (Legal Business Name): KEVIN KUCERA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 E WALTON BLVD
PONTIAC MI
48340-1277
US

IV. Provider business mailing address

5415 INVERRARY LN
COMMERCE TOWNSHIP MI
48382-1010
US

V. Phone/Fax

Practice location:
  • Phone: 248-334-1896
  • Fax:
Mailing address:
  • Phone: 313-456-5628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302040219
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: