=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871636274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSS A DEGRAAF R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4443 BRETON RD SE STE A
-----------------------------------------------------
City | KENTWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-8424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-281-3519
-----------------------------------------------------
Fax | 616-281-4088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1654 BRIDLE CREEK ST SE
-----------------------------------------------------
City | KENTWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-4933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-455-1184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302020588
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------