Provider Demographics
NPI:1790881753
Name:KINZEL, TERA SHAWN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TERA
Middle Name:SHAWN
Last Name:KINZEL
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 1:9873 TERRA W
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9637
Mailing Address - Country:US
Mailing Address - Phone:231-922-2672
Mailing Address - Fax:231-947-3102
Practice Address - Street 1:1217 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2928
Practice Address - Country:US
Practice Address - Phone:231-947-9825
Practice Address - Fax:231-947-3102
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist