MEDICARE: MS. MICHELLE LYNN BOAHBEDASON

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	5302029415	MI

General Provider Information

NPI Number	:	1497033732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE LYNN BOAHBEDASON

Provider Business Mailing Address
First Line	:	3191 28TH ST SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1110
Country	:	US
Telephone Number	:	616-534-5533
Fax Number	:

Provider Business Practice Location Address
First Line	:	4252 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-3607
Country	:	US
Telephone Number	:	616-281-1323
Fax Number	:	616-281-1330

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

Provider Enumeration Date	:	08/03/2011
Last Update Date	:	01/12/2023

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