Healthcare Provider Details

I. General information

NPI: 1366212235
Provider Name (Legal Business Name): MICHAEL JOHN BOUTHILLIER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE STE 5100
GRAND RAPIDS MI
49503-2572
US

IV. Provider business mailing address

25 MICHIGAN ST NE STE 5100
GRAND RAPIDS MI
49503-2572
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-2100
  • Fax:
Mailing address:
  • Phone: 616-267-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number5302024648
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: