Provider Demographics
NPI:1316220502
Name:FOSTER, KEVIN MARK (RPH, MBA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MARK
Last Name:FOSTER
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27118 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-2915
Mailing Address - Country:US
Mailing Address - Phone:586-447-1436
Mailing Address - Fax:586-498-1002
Practice Address - Street 1:27118 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-2915
Practice Address - Country:US
Practice Address - Phone:586-447-1436
Practice Address - Fax:586-498-1002
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025685183500000X
FLPS 26462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist