=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649817453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA DAWN ZUKOWSKI RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2019
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3833 N DIXIE HWY
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-4489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-289-6310
-----------------------------------------------------
Fax | 734-289-6312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5119 OAKHAVEN LN
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48161-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-652-9751
-----------------------------------------------------
Fax | 734-289-6312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5315107100
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 5315107100
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------