Provider Demographics
NPI:1477069789
Name:PHELPS, MARK KEVIN JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KEVIN
Last Name:PHELPS
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1131
Mailing Address - Country:US
Mailing Address - Phone:989-345-0080
Mailing Address - Fax:
Practice Address - Street 1:501 E HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1131
Practice Address - Country:US
Practice Address - Phone:989-345-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist