Provider Demographics
NPI:1568885556
Name:PITTELKO, MARY (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PITTELKO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2151
Mailing Address - Country:US
Mailing Address - Phone:269-373-9068
Mailing Address - Fax:
Practice Address - Street 1:1195 M 89
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1135
Practice Address - Country:US
Practice Address - Phone:269-685-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034952183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist