Basic Information
| Provider Information | |||||||||
| NPI: | 1902313687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUZAKIS | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 913 SAND LAKE DR | ||||||||
| Address2: | |||||||||
| City: | ZEELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494649174 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5838 METRO WAY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162495300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2018 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302024518 | MI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.