Healthcare Provider Details

I. General information

NPI: 1760638019
Provider Name (Legal Business Name): KENTWOOD PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N MILL ST
SAINT LOUIS MI
48880-1521
US

IV. Provider business mailing address

2480 44TH ST SE
KENTWOOD MI
49512-9090
US

V. Phone/Fax

Practice location:
  • Phone: 989-681-6633
  • Fax: 989-681-6644
Mailing address:
  • Phone: 616-827-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5901008943
License Number StateMI

VIII. Authorized Official

Name: MARK DOWNER
Title or Position: ACCOUNTS PAYABLE
Credential:
Phone: 616-827-9100