Provider Demographics
NPI:1003040635
Name:NOWAK, KEITH DAVID (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DAVID
Last Name:NOWAK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S LAKE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9376
Mailing Address - Country:US
Mailing Address - Phone:231-536-0901
Mailing Address - Fax:
Practice Address - Street 1:250 S LAKE ST
Practice Address - Street 2:SUITE A
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9376
Practice Address - Country:US
Practice Address - Phone:231-536-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist