Provider Demographics
NPI:1225352909
Name:KENTWOOD PHARMACY LLC
Entity Type:Organization
Organization Name:KENTWOOD PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MULDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-827-9100
Mailing Address - Street 1:2480 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512
Mailing Address - Country:US
Mailing Address - Phone:616-827-9100
Mailing Address - Fax:616-827-9116
Practice Address - Street 1:2026 BOSTON ST. SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-452-9734
Practice Address - Fax:616-452-7255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENTWOOD PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301009297333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy