Provider Demographics
NPI:1154649127
Name:RAEHTZ, TODD R (RPH)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:R
Last Name:RAEHTZ
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 1:11278 HUCKLEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-8958
Mailing Address - Country:US
Mailing Address - Phone:866-964-2638
Mailing Address - Fax:866-481-5199
Practice Address - Street 1:112 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9680
Practice Address - Country:US
Practice Address - Phone:866-964-2638
Practice Address - Fax:866-481-5199
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist