Healthcare Provider Details

I. General information

NPI: 1760696744
Provider Name (Legal Business Name): CAROLYN GUTAI MAURER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WEALTHY ST SE SUITE 105
GRAND RAPIDS MI
49506-2969
US

IV. Provider business mailing address

7538 LIME HOLLOW DR SE
GRAND RAPIDS MI
49546-7439
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-7799
  • Fax:
Mailing address:
  • Phone: 616-949-4727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302023902
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: