Provider Demographics
NPI:1528359973
Name:DELEEUW, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DELEEUW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3236 E. COLBY RD.
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461
Mailing Address - Country:US
Mailing Address - Phone:231-893-0310
Mailing Address - Fax:
Practice Address - Street 1:3263 COLBY RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-8601
Practice Address - Country:US
Practice Address - Phone:231-893-0310
Practice Address - Fax:231-894-4050
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist