Provider Demographics
NPI:1326426131
Name:PETZAK, KAYLIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KAYLIN
Middle Name:
Last Name:PETZAK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-9562
Mailing Address - Country:US
Mailing Address - Phone:231-510-0728
Mailing Address - Fax:
Practice Address - Street 1:33 S PERE MARQUETTE HWY
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2441
Practice Address - Country:US
Practice Address - Phone:231-845-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2265401183500000X
MI2265402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist