Healthcare Provider Details

I. General information

NPI: 1376953034
Provider Name (Legal Business Name): PETER KAMPSTRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2014
Last Update Date: 05/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14640 PARDEE RD
TAYLOR MI
48180-4739
US

IV. Provider business mailing address

14640 PARDEE RD
TAYLOR MI
48180-4739
US

V. Phone/Fax

Practice location:
  • Phone: 734-374-4233
  • Fax: 734-374-4265
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number5302030951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: