Healthcare Provider Details

I. General information

NPI: 1356946552
Provider Name (Legal Business Name): ASHLEY DIEDRICH PHARM. D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/11/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 LEONARD ST NE STE 5
GRAND RAPIDS MI
49525-6901
US

IV. Provider business mailing address

2680 LEONARD ST NE STE 5
GRAND RAPIDS MI
49525-6901
US

V. Phone/Fax

Practice location:
  • Phone: 616-224-1121
  • Fax: 616-224-3001
Mailing address:
  • Phone: 616-224-1121
  • Fax: 616-224-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302038678
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: