Healthcare Provider Details

I. General information

NPI: 1033713847
Provider Name (Legal Business Name): AUSTIN RYKSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 HEALTH DR SW
WYOMING MI
49519-9625
US

IV. Provider business mailing address

4029 42ND ST SW
GRANDVILLE MI
49418-2305
US

V. Phone/Fax

Practice location:
  • Phone: 616-249-9161
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302041882
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: