Provider Demographics
NPI:1346419892
Name:KENTWOOD PHARMACY
Entity Type:Organization
Organization Name:KENTWOOD PHARMACY
Other - Org Name:KENTWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPER MANG
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-581-7093
Mailing Address - Street 1:2480 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 44TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-9090
Practice Address - Country:US
Practice Address - Phone:616-827-9100
Practice Address - Fax:616-827-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI53010088113336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2370841OtherOTHER ID NUMBER
2370841OtherOTHER ID NUMBER