Provider Demographics
NPI:1659710895
Name:CORBETT, EWA MALGORZATA (RPH)
Entity Type:Individual
Prefix:
First Name:EWA
Middle Name:MALGORZATA
Last Name:CORBETT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5510
Mailing Address - Country:US
Mailing Address - Phone:616-459-6203
Mailing Address - Fax:616-454-8777
Practice Address - Street 1:1225 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5510
Practice Address - Country:US
Practice Address - Phone:616-459-6203
Practice Address - Fax:616-454-8777
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4473890003Medicare NSC