Provider Demographics
NPI:1346704566
Name:ERICKSEN, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:ERICKSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 LEXINGTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5649
Mailing Address - Country:US
Mailing Address - Phone:989-954-1234
Mailing Address - Fax:
Practice Address - Street 1:3596 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-1659
Practice Address - Country:US
Practice Address - Phone:616-647-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351013905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist