Healthcare Provider Details

I. General information

NPI: 1497033732
Provider Name (Legal Business Name): MS. MICHELLE LYNN BOAHBEDASON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4252 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-3607
US

IV. Provider business mailing address

3191 28TH ST SW
GRANDVILLE MI
49418-1110
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-1323
  • Fax: 616-281-1330
Mailing address:
  • Phone: 616-534-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302029415
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: