MEDICARE: MR. THOMAS PAUL ALTENBERGER R.PH, MBA

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	5302032992	MI

General Provider Information

NPI Number	:	1447557418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS PAUL ALTENBERGER R.PH, MBA

Provider Business Mailing Address
First Line	:	3031 POPLAR CREEK DR SE
Second Line	:	SUITE 103
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5682
Country	:	US
Telephone Number	:	616-975-7590
Fax Number	:	616-975-7596

Provider Business Practice Location Address
First Line	:	3031 POPLAR CREEK DR SE
Second Line	:	SUITE 103
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5682
Country	:	US
Telephone Number	:	616-975-7590
Fax Number	:	616-975-7596

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

Provider Enumeration Date	:	02/27/2011
Last Update Date	:	02/27/2011

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