Provider Demographics
NPI:1316113921
Name:FANTICH, KEVIN
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:FANTICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26711 NORTHWESTERN HIGHWAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26711 NORTHWESTERN HIGHWAY
Practice Address - Street 2:SUITE 400
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2154
Practice Address - Country:US
Practice Address - Phone:248-948-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-03
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS486031835P0018X
MI5302035536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302035536OtherMI CONTROLLED SUBSTANCE LICENSE
FLPS48603OtherFL CONTROLLED SUBSTANCE LICENSE