Healthcare Provider Details

I. General information

NPI: 1588844203
Provider Name (Legal Business Name): MARTIN HELMUT KOCAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-6581
  • Fax: 231-935-6439
Mailing address:
  • Phone: 231-935-6581
  • Fax: 231-935-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302029736
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: