Healthcare Provider Details

I. General information

NPI: 1194490557
Provider Name (Legal Business Name): DANIEL BOLDT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

12177 MILLPOND DR NW
GRAND RAPIDS MI
49534-9599
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6383
  • Fax: 616-685-3057
Mailing address:
  • Phone: 616-560-7965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number5302038930
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: