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General NPI Number Information
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NPI Number | 1558478610
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Entity Type | Organization
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Legal Business Name | KENTWOOD PHARMACY
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Dates
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Enumeration Date | 08/24/2006
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Last Update Date | 02/27/2008
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Provider Practice Location Address
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Address Line | 6680 KALAMAZOO AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-7030
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Country | US
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Telephone | 616-554-1964
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Fax | 616-554-3140
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Provider Business Mailing Address
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Address Line | 6680 KALAMAZOO AVENUE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49508
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Country | US
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Telephone | 616-554-1964
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Fax | 616-554-3140
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Authorized Official
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Title or Position | OWNER
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Name | MR. KIM MULDER
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Credential |
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Telephone | 616-827-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5301007344
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License Number State | MI
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