Healthcare Provider Details

I. General information

NPI: 1043747801
Provider Name (Legal Business Name): KELLI DEYOUNG R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8278
  • Fax: 616-940-5805
Mailing address:
  • Phone: 616-965-8278
  • Fax: 616-940-5805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302030161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: