MEDICARE: MR. GARY ALAN VACHON R.PH., M.M.

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	1835P1200X	Pharmacotherapy Pharmacist	5302025473	MI

General Provider Information

NPI Number	:	1861729675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY ALAN VACHON R.PH., M.M.

Provider Business Mailing Address
First Line	:	1004 ALGER ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3806
Country	:	US
Telephone Number	:	616-490-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	3876 E PARIS AVE SE
Second Line	:	SUITE 13
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-3974
Country	:	US
Telephone Number	:	616-777-0340
Fax Number	:	616-855-0937

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

Provider Enumeration Date	:	11/16/2009
Last Update Date	:	11/16/2009

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