Healthcare Provider Details

I. General information

NPI: 1700102993
Provider Name (Legal Business Name): MIDTOWNE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MIDTOWNE ST NE SUITE 103
GRAND RAPIDS MI
49503-5729
US

IV. Provider business mailing address

555 MIDTOWNE ST NE SUITE 103
GRAND RAPIDS MI
49503-5729
US

V. Phone/Fax

Practice location:
  • Phone: 616-554-1964
  • Fax:
Mailing address:
  • Phone: 616-554-1964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009298
License Number StateMI

VIII. Authorized Official

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