Provider Demographics
NPI:1003984527
Name:BALLENTINE, RICK (RPH)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:BALLENTINE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:3482 MAIN STREET
Mailing Address - City:DECKERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48427-0067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3482 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DECKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48427-0067
Practice Address - Country:US
Practice Address - Phone:810-376-2825
Practice Address - Fax:810-376-8355
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI21235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist