Provider Demographics
NPI:1063373348
Name:KIENITZ, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KIENITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W WHEATLAND AVE
Mailing Address - Street 2:
Mailing Address - City:REMUS
Mailing Address - State:MI
Mailing Address - Zip Code:49340-5115
Mailing Address - Country:US
Mailing Address - Phone:989-967-3360
Mailing Address - Fax:989-967-3374
Practice Address - Street 1:144 W WHEATLAND AVE
Practice Address - Street 2:
Practice Address - City:REMUS
Practice Address - State:MI
Practice Address - Zip Code:49340-5115
Practice Address - Country:US
Practice Address - Phone:989-967-3360
Practice Address - Fax:989-967-3374
Is Sole Proprietor?:No
Enumeration Date:2025-11-18
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020274071835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care