Healthcare Provider Details

I. General information

NPI: 1881782076
Provider Name (Legal Business Name): RALPH DAVID MARTIN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 WEALTHY ST SE
GRAND RAPIDS MI
49506-3032
US

IV. Provider business mailing address

1751 COUNTRY CLUB DR NE
GRAND RAPIDS MI
49505-4881
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-0711
  • Fax:
Mailing address:
  • Phone: 616-363-4773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302023857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: