Provider Demographics
NPI:1215218243
Name:JALOWIECZ, WALTER GERARD (RPH)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:GERARD
Last Name:JALOWIECZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5289 SILVERSTONE DR NE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8269
Mailing Address - Country:US
Mailing Address - Phone:616-647-9122
Mailing Address - Fax:616-647-9058
Practice Address - Street 1:11980 FULTON ST E
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-9428
Practice Address - Country:US
Practice Address - Phone:616-897-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist