Provider Demographics
NPI:1316053739
Name:PICKELL, MARK G (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:PICKELL
Suffix:
Gender:M
Credentials:RPH
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Mailing Address - Street 1:64580 VAN DYKE RD
Mailing Address - Street 2:STE G
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2857
Mailing Address - Country:US
Mailing Address - Phone:586-336-0772
Mailing Address - Fax:586-336-0805
Practice Address - Street 1:64580 VAN DYKE RD
Practice Address - Street 2:STE G
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2857
Practice Address - Country:US
Practice Address - Phone:586-336-0772
Practice Address - Fax:586-336-0805
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5302030368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist