Provider Demographics
NPI:1063012417
Name:PISANO, KIM MICHELLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MICHELLE
Last Name:PISANO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MICHELLE
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:613 FAIRVIEW AVE NE APT 3
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1897
Mailing Address - Country:US
Mailing Address - Phone:405-227-1526
Mailing Address - Fax:
Practice Address - Street 1:412 OAKS XING
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1900
Practice Address - Country:US
Practice Address - Phone:269-685-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist