Healthcare Provider Details

I. General information

NPI: 1861245557
Provider Name (Legal Business Name): JODY ANN MEHREN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

320 GREENRIDGE DR NW
WALKER MI
49544-6942
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5036
  • Fax:
Mailing address:
  • Phone: 616-890-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302032017
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: