Healthcare Provider Details

I. General information

NPI: 1265431852
Provider Name (Legal Business Name): CATHLEEN MARIE EDICK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 76TH ST SW MAILCODE: GR761120
GRAND RAPIDS MI
49518-8700
US

IV. Provider business mailing address

850 76TH ST SW MAILCODE: GR761120
GRAND RAPIDS MI
49518-8700
US

V. Phone/Fax

Practice location:
  • Phone: 616-878-2324
  • Fax: 616-878-8850
Mailing address:
  • Phone: 616-878-2324
  • Fax: 616-878-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302034435
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11655
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: