MEDICARE: DR. CARMEN MITCHELL DOCTER PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302038544	MI

General Provider Information

NPI Number	:	1235666827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARMEN MITCHELL DOCTER PHARMD

Provider Business Mailing Address
First Line	:	360 DIVISION AVE S STE 1E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4501
Country	:	US
Telephone Number	:	616-685-1089
Fax Number	:	616-685-1090

Provider Business Practice Location Address
First Line	:	360 DIVISION AVE S STE 1E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4501
Country	:	US
Telephone Number	:	616-685-1080
Fax Number	:	616-685-1090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2017
Last Update Date	:	05/15/2017

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