Healthcare Provider Details

I. General information

NPI: 1235008632
Provider Name (Legal Business Name): IRENE OMWEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-2402
US

IV. Provider business mailing address

10897 48TH AV. E-02-D
ALLENDALE MI
49401
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-1221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5351017398
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: