Healthcare Provider Details

I. General information

NPI: 1992214720
Provider Name (Legal Business Name): MOLLIE MAE REIDENBACH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 76TH ST SW
BYRON CENTER MI
49315-8510
US

IV. Provider business mailing address

1485 HIDDEN VALLEY DR SE APT 11
KENTWOOD MI
49508-6483
US

V. Phone/Fax

Practice location:
  • Phone: 616-878-8009
  • Fax: 616-878-8850
Mailing address:
  • Phone: 231-690-3168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302041942
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: