Basic Information
| Provider Information | |||||||||
| NPI: | 1770999880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15950 HOLLAND RD | ||||||||
| Address2: | |||||||||
| City: | BROOKPARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441423352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169784156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5500 ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490377314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699665600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03233705 | OH | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.