Provider Demographics
NPI:1104193275
Name:VIDETICH, GREGORY JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JOHN
Last Name:VIDETICH
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 1:1010 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2254
Mailing Address - Country:US
Mailing Address - Phone:231-592-0385
Mailing Address - Fax:231-592-9749
Practice Address - Street 1:1010 S STATE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2254
Practice Address - Country:US
Practice Address - Phone:231-592-0385
Practice Address - Fax:231-592-9749
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist