Healthcare Provider Details

I. General information

NPI: 1114137882
Provider Name (Legal Business Name): THOMAS NELSON VERHAGE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6680 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-7030
US

IV. Provider business mailing address

4528 CARRICK AVE SE
KENTWOOD MI
49508-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-554-1964
  • Fax: 616-554-3140
Mailing address:
  • Phone: 616-532-3934
  • Fax: 616-532-1143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302020582
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: