Healthcare Provider Details

I. General information

NPI: 1720372642
Provider Name (Legal Business Name): LAURA LEIPHAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 28TH ST SE
GRAND RAPIDS MI
49512-2049
US

IV. Provider business mailing address

5120 28TH ST SE
GRAND RAPIDS MI
49512-2049
US

V. Phone/Fax

Practice location:
  • Phone: 708-583-6990
  • Fax: 708-402-9102
Mailing address:
  • Phone: 616-222-4890
  • Fax: 616-222-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.295758
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302036998
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: