Healthcare Provider Details

I. General information

NPI: 1821076977
Provider Name (Legal Business Name): JACQUELINE LEE KOWALCZYK R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BURLINGAME AVE SW
WYOMING MI
49509-2610
US

IV. Provider business mailing address

3878 TALL OAK CT SW
GRAND RAPIDS MI
49534-6685
US

V. Phone/Fax

Practice location:
  • Phone: 616-538-1490
  • Fax:
Mailing address:
  • Phone: 616-453-6586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302025887
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: