Healthcare Provider Details

I. General information

NPI: 1922058908
Provider Name (Legal Business Name): DYKSTRA DRUG STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 DOUGLAS AVE
HOLLAND MI
49424-2188
US

IV. Provider business mailing address

91 DOUGLAS AVE PO BOX 8249
HOLLAND MI
49424-2188
US

V. Phone/Fax

Practice location:
  • Phone: 616-392-8130
  • Fax: 616-392-8025
Mailing address:
  • Phone: 616-392-8130
  • Fax: 616-392-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301001241
License Number StateMI

VIII. Authorized Official

Name: MR. THOMAS D KLAASEN
Title or Position: OWNER/PRESIDENT
Credential: RPH
Phone: 616-392-8130