Healthcare Provider Details

I. General information

NPI: 1003984527
Provider Name (Legal Business Name): RICK BALLENTINE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3482 MAIN STREET
DECKERVILLE MI
48427-0067
US

IV. Provider business mailing address

PO BOX 67 3482 MAIN STREET
DECKERVILLE MI
48427-0067
US

V. Phone/Fax

Practice location:
  • Phone: 810-376-2825
  • Fax: 810-376-8355
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: