Provider Demographics
NPI:1275805822
Name:MICKIEWICZ, ROBERT J
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MICKIEWICZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20000 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20000 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1011
Practice Address - Country:US
Practice Address - Phone:734-464-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-29
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist