Provider Demographics
NPI:1073946190
Name:HENNING, LYDIA MARIE (PHARM D)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIE
Last Name:HENNING
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MARIE
Other - Last Name:CORMIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:2519 LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3120
Mailing Address - Country:US
Mailing Address - Phone:616-206-6892
Mailing Address - Fax:
Practice Address - Street 1:2519 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3120
Practice Address - Country:US
Practice Address - Phone:616-206-6892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist