Healthcare Provider Details

I. General information

NPI: 1306442488
Provider Name (Legal Business Name): DEIDRE ELIZABETH HUTSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2020
Last Update Date: 12/05/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 APPLE ORCHARD DR NE
GRAND RAPIDS MI
49525-9785
US

IV. Provider business mailing address

1520 HIDDEN CREEK CIRCLE DR NE APT F
GRAND RAPIDS MI
49505-5477
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-3676
  • Fax:
Mailing address:
  • Phone: 616-970-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302413042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: