Provider Demographics
NPI:1679723043
Name:KILLEWALD, CHARLES W (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:W
Last Name:KILLEWALD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 SCOTT B DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-3566
Mailing Address - Country:US
Mailing Address - Phone:810-326-2605
Mailing Address - Fax:810-326-2605
Practice Address - Street 1:4100 S RIVER RD
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2909
Practice Address - Country:US
Practice Address - Phone:810-326-4717
Practice Address - Fax:810-329-8926
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist