MEDICARE: MR. MICHAEL ROBERT DEBOER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302030990	MI

General Provider Information

NPI Number	:	1306175468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL ROBERT DEBOER

Provider Business Mailing Address
First Line	:	3876 E PARIS AVE SE
Second Line	:	SUITE 13
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-3974
Country	:	US
Telephone Number	:	616-977-9700
Fax Number	:	616-855-0937

Provider Business Practice Location Address
First Line	:	3876 E PARIS AVE SE
Second Line	:	SUITE 13
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-3974
Country	:	US
Telephone Number	:	616-977-9700
Fax Number	:	616-855-0937

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2009
Last Update Date	:	12/18/2009

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