Provider Demographics
NPI:1295823805
Name:ZWIESLER, MARTIN LEO (RPH)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LEO
Last Name:ZWIESLER
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 1:21832 CUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2122
Mailing Address - Country:US
Mailing Address - Phone:248-349-7573
Mailing Address - Fax:
Practice Address - Street 1:25853 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2934
Practice Address - Country:US
Practice Address - Phone:313-562-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302021616OtherPHARMACIST LICENSE NUMBER