Provider Demographics
NPI:1104829647
Name:JOLDERSMA, MICHAEL JAMES (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:JOLDERSMA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25070 628TH AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-5212
Mailing Address - Country:US
Mailing Address - Phone:320-693-9285
Mailing Address - Fax:320-693-7039
Practice Address - Street 1:975 E FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-2613
Practice Address - Country:US
Practice Address - Phone:320-693-7034
Practice Address - Fax:320-693-7039
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114903-8183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist