Healthcare Provider Details

I. General information

NPI: 1225253974
Provider Name (Legal Business Name): CANCER & HEMATOLOGY CENTERS OF WESTERN MI, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2379
US

IV. Provider business mailing address

710 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-4861
  • Fax: 616-389-0977
Mailing address:
  • Phone: 616-389-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008064
License Number StateMI

VIII. Authorized Official

Name: KIMBERLY MELGAREJO
Title or Position: PHARMACIST/DIRECTOR
Credential: PHARMD
Phone: 616-977-4850