Provider Demographics
NPI:1942594270
Name:KNOWLTON, MARK (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 CHICAGO DR
Mailing Address - Street 2:T-0399
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9244
Mailing Address - Country:US
Mailing Address - Phone:616-457-2730
Mailing Address - Fax:616-457-2730
Practice Address - Street 1:334 CHICAGO DR
Practice Address - Street 2:T-0399
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9244
Practice Address - Country:US
Practice Address - Phone:616-457-2730
Practice Address - Fax:616-457-2730
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist