Provider Demographics
NPI:1750647921
Name:KRAFT, PHILIP GORDON
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:GORDON
Last Name:KRAFT
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 1:30550 STEPHENSON HWY
Mailing Address - Street 2:COSTCO PHARMACY
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1611
Mailing Address - Country:US
Mailing Address - Phone:248-616-0064
Mailing Address - Fax:248-616-0064
Practice Address - Street 1:30550 STEPHENSON HWY
Practice Address - Street 2:COSTCO PHARMACY
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1611
Practice Address - Country:US
Practice Address - Phone:248-616-0064
Practice Address - Fax:248-616-0064
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist