MEDICARE: DR. TRACY LYN RIDDER PHARMD

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	5302031371	MI

General Provider Information

NPI Number	:	1730159021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY LYN RIDDER PHARMD

Provider Business Mailing Address
First Line	:	4591 CREEK VIEW DR
Second Line	:
City	:	HUDSONVILLE
State	:	MI
Zip	:	49426-1905
Country	:	US
Telephone Number	:	616-881-2419
Fax Number	:

Provider Business Practice Location Address
First Line	:	3960 44TH ST SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-2420
Country	:	US
Telephone Number	:	616-534-9649
Fax Number	:	616-538-6730

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

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	07/08/2007

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