Provider Demographics
NPI:1689128761
Name:RUSZKOWSKI, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RUSZKOWSKI
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 1:899 CAMELLIA LN
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-8919
Mailing Address - Country:US
Mailing Address - Phone:616-901-9286
Mailing Address - Fax:
Practice Address - Street 1:100 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4526
Practice Address - Country:US
Practice Address - Phone:616-965-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020420571835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care