Healthcare Provider Details

I. General information

NPI: 1235257387
Provider Name (Legal Business Name): CANCER AND HEMATOLOGY CENTERS OF WESTERN MI, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MICHIGAN AVE NE SUITE 3100
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

145 MICHIGAN AVE NE SUITE 3100
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-4840
  • Fax: 616-885-1459
Mailing address:
  • Phone: 616-977-4840
  • Fax: 616-885-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301006326
License Number StateMI

VIII. Authorized Official

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