Healthcare Provider Details

I. General information

NPI: 1225314446
Provider Name (Legal Business Name): JENNIFER MARIE DUDEK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5241 NORTHLAND DR NE
GRAND RAPIDS MI
49525-1041
US

IV. Provider business mailing address

3669 WINDSHIRE DR SE
GRAND RAPIDS MI
49546-3684
US

V. Phone/Fax

Practice location:
  • Phone: 616-447-2788
  • Fax:
Mailing address:
  • Phone: 616-575-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302029305
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: