Provider Demographics
NPI:1841576865
Name:PATRICK, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:PATRICK
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 1:5815 GULL RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1094
Mailing Address - Country:US
Mailing Address - Phone:269-226-9483
Mailing Address - Fax:269-226-9462
Practice Address - Street 1:5815 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1094
Practice Address - Country:US
Practice Address - Phone:269-226-9483
Practice Address - Fax:269-226-9462
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist