Healthcare Provider Details

I. General information

NPI: 1225352909
Provider Name (Legal Business Name): KENTWOOD PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2010
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026 BOSTON ST. SE
GRAND RAPIDS MI
49506
US

IV. Provider business mailing address

2480 44TH ST SE
GRAND RAPIDS MI
49512
US

V. Phone/Fax

Practice location:
  • Phone: 616-452-9734
  • Fax: 616-452-7255
Mailing address:
  • Phone: 616-827-9100
  • Fax: 616-827-9116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301009297
License Number StateMI

VIII. Authorized Official

Name: MR. KIM MULDER
Title or Position: CEO
Credential:
Phone: 616-827-9100