Provider Demographics
NPI:1508287293
Name:BRISKE, KERRY (RPH)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:BRISKE
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 1:5500 CLYDE PARK AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9525
Mailing Address - Country:US
Mailing Address - Phone:616-530-7133
Mailing Address - Fax:616-530-7165
Practice Address - Street 1:5500 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9525
Practice Address - Country:US
Practice Address - Phone:616-530-7133
Practice Address - Fax:616-530-7165
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302026104OtherPHARMACY LICENSE NUMBER