Healthcare Provider Details

I. General information

NPI: 1730330341
Provider Name (Legal Business Name): LARRY ANDREW CUSTER R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 BRETON RD SE SUITE 202
GRAND RAPIDS MI
49506-4810
US

IV. Provider business mailing address

1925 BRETON RD SE SUITE 202
GRAND RAPIDS MI
49506-4810
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-4757
  • Fax: 616-252-0724
Mailing address:
  • Phone: 616-252-4757
  • Fax: 616-252-0724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number024244
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: