Healthcare Provider Details

I. General information

NPI: 1578134409
Provider Name (Legal Business Name): ROY WERTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 BURTON ST SE
GRAND RAPIDS MI
49546-4806
US

IV. Provider business mailing address

7305 PINEGROVE DR
JENISON MI
49428-7784
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-5710
  • Fax: 616-954-9459
Mailing address:
  • Phone: 616-430-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303004508
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: