Healthcare Provider Details

I. General information

NPI: 1689279366
Provider Name (Legal Business Name): PAUL DAVID HARCOURT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 APPLE ORCHARD DR NE
GRAND RAPIDS MI
49525-9785
US

IV. Provider business mailing address

7104 30TH ST SE
ADA MI
49301-8593
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-3676
  • Fax: 866-394-0043
Mailing address:
  • Phone: 616-617-0151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302039483
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: