=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760780811
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD MARK KESEMEYER RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2011
-----------------------------------------------------
Last Update Date | 03/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 DAVISON RD STE A
-----------------------------------------------------
City | BURTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48509-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-742-0217
-----------------------------------------------------
Fax | 810-744-9165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5426 HICKORY CIR
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48433-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-230-8225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302024004
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------