Healthcare Provider Details

I. General information

NPI: 1346242666
Provider Name (Legal Business Name): WESTSIDE PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 N DIBBLE BVD
LANSING MI
48917
US

IV. Provider business mailing address

632 N DIBBLE BVD
LANSING MI
48917
US

V. Phone/Fax

Practice location:
  • Phone: 517-323-2382
  • Fax: 517-323-0459
Mailing address:
  • Phone: 517-323-2382
  • Fax: 517-323-0459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301005171
License Number StateMI

VIII. Authorized Official

Name: MR. GREGORY S BOVEE
Title or Position: PRESIDENT/TREASURER
Credential: RPH
Phone: 517-323-2382