Provider Demographics
NPI:1881143667
Name:BERKENPAS, MITCHELL BRIAN
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:BRIAN
Last Name:BERKENPAS
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 1:9400 WESTVIEW DR SE
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9324
Mailing Address - Country:US
Mailing Address - Phone:616-877-0736
Mailing Address - Fax:
Practice Address - Street 1:4382 14 MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7838
Practice Address - Country:US
Practice Address - Phone:888-258-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist