Healthcare Provider Details

I. General information

NPI: 1114098084
Provider Name (Legal Business Name): BETH LILLIAN TWYDELL PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

2902 BRADFORD ST NE
GRAND RAPIDS MI
49525-6427
US

V. Phone/Fax

Practice location:
  • Phone: 616-885-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302032104
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: