Provider Demographics
NPI:1295160836
Name:GWIZDALA, ADAM RUSSELL (DO, PHARMD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:RUSSELL
Last Name:GWIZDALA
Suffix:
Gender:M
Credentials:DO, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16923 PIPER WAY APT 304
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9075
Mailing Address - Country:US
Mailing Address - Phone:989-798-0222
Mailing Address - Fax:
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-672-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037090183500000X
MI5151015914390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183500000XPharmacy Service ProvidersPharmacist