MEDICARE: MRS. TERA SHAWN KINZEL RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302032565	MI

General Provider Information

NPI Number	:	1790881753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERA SHAWN KINZEL RPH

Provider Business Mailing Address
First Line	:	9873 TERRA W
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-9637
Country	:	US
Telephone Number	:	231-922-2672
Fax Number	:	231-947-3102

Provider Business Practice Location Address
First Line	:	1217 E FRONT ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-2928
Country	:	US
Telephone Number	:	231-947-9825
Fax Number	:	231-947-3102

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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