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General NPI Number Information
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NPI Number | 1720378045
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Entity Type | Individual
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Provider Name | KEITH DARREL HAZELY SR. PHARMACIST
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Gender | Male
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Dates
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Enumeration Date | 04/08/2011
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Last Update Date | 04/08/2011
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Provider Practice Location Address
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Address Line | 31700 VAN DYKE AVE STE 190
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City | WARREN
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State | MI
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Zip | 48093-7951
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Country | US
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Telephone | 586-276-8040
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Fax | 586-276-8039
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Provider Business Mailing Address
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Address Line | 13701 VAN DYKE SUITE 190
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City | WARREN
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State | MI
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Zip | 48093-7951
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Country | US
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Telephone | 586-276-8040
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Fax | 586-276-8039
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5302024376
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License Number State | MI
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