Provider Demographics
NPI:1063830123
Name:GRODUS, THOMAS E (BS PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:E
Last Name:GRODUS
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8503
Mailing Address - Country:US
Mailing Address - Phone:616-393-8071
Mailing Address - Fax:
Practice Address - Street 1:2629 N PARK DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8503
Practice Address - Country:US
Practice Address - Phone:616-393-8071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist