Healthcare Provider Details

I. General information

NPI: 1720378045
Provider Name (Legal Business Name): KEITH DARREL HAZELY SR. PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31700 VAN DYKE AVE STE 190
WARREN MI
48093-7951
US

IV. Provider business mailing address

13701 VAN DYKE SUITE 190
WARREN MI
48093-7951
US

V. Phone/Fax

Practice location:
  • Phone: 586-276-8040
  • Fax: 586-276-8039
Mailing address:
  • Phone: 586-276-8040
  • Fax: 586-276-8039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302024376
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: