Provider Demographics
NPI:1982704664
Name:KILLEWALD, BRIAN K (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:KILLEWALD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MADISON ST
Mailing Address - Street 2:ATTN: PHARMACY DEPT
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1143
Mailing Address - Country:US
Mailing Address - Phone:269-789-3905
Mailing Address - Fax:269-789-3975
Practice Address - Street 1:200 N MADISON ST
Practice Address - Street 2:ATTN: PHARMACY DEPT
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1143
Practice Address - Country:US
Practice Address - Phone:269-789-3905
Practice Address - Fax:269-789-3975
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist