MEDICARE: TIMOTHY BOUWKAMP RPH

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	5302030343	MI

General Provider Information

NPI Number	:	1396715223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY BOUWKAMP RPH

Provider Business Mailing Address
First Line	:	1415 FULTON ST E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-3853
Country	:	US
Telephone Number	:	616-774-9422
Fax Number	:	616-774-9380

Provider Business Practice Location Address
First Line	:	1415 FULTON ST E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-3853
Country	:	US
Telephone Number	:	616-774-9422
Fax Number	:	616-774-9380

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

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	10/11/2007

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