Provider Demographics
NPI:1811332414
Name:KUCHARCZYK, SHANE ROBERT (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ROBERT
Last Name:KUCHARCZYK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:HARBOR BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:48441-8979
Mailing Address - Country:US
Mailing Address - Phone:810-841-5910
Mailing Address - Fax:
Practice Address - Street 1:1115 S LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:HARBOR BEACH
Practice Address - State:MI
Practice Address - Zip Code:48441-8979
Practice Address - Country:US
Practice Address - Phone:810-841-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist