Healthcare Provider Details

I. General information

NPI: 1700512464
Provider Name (Legal Business Name): NIKOTA DANIEL REDMOND PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/25/2025
Certification Date: 07/27/2023
Deactivation Date: 07/27/2023
Reactivation Date: 07/25/2025

III. Provider practice location address

2425 ALPINE AVE NW
GRAND RAPIDS MI
49544-1956
US

IV. Provider business mailing address

912 BARAGA ST NE
GRAND RAPIDS MI
49503-1803
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-6010
  • Fax:
Mailing address:
  • Phone: 517-852-4296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: