Healthcare Provider Details

I. General information

NPI: 1063961167
Provider Name (Legal Business Name): LINDA LEE IDE-WAY R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 ALPINE AVE NW
COMSTOCK PARK MI
49321-8350
US

IV. Provider business mailing address

3901 ALPINE AVE NW
COMSTOCK PARK MI
49321-8350
US

V. Phone/Fax

Practice location:
  • Phone: 616-647-9302
  • Fax: 616-647-9820
Mailing address:
  • Phone: 616-647-9302
  • Fax: 616-647-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302022230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: