Healthcare Provider Details

I. General information

NPI: 1841446192
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: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 W WRIGHT AVE
SHEPHERD MI
48883-2502
US

IV. Provider business mailing address

2480 44TH ST SE
KENTWOOD MI
49512-9090
US

V. Phone/Fax

Practice location:
  • Phone: 616-827-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301008951
License Number StateMI

VIII. Authorized Official

Name: LINDA MALINOWSKI
Title or Position: CONTROLLER
Credential:
Phone: 616-827-9100