Provider Demographics
NPI:1376139824
Name:REDDER, COLTEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:COLTEN
Middle Name:
Last Name:REDDER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9354
Mailing Address - Country:US
Mailing Address - Phone:616-402-3465
Mailing Address - Fax:
Practice Address - Street 1:4665 44TH ST SE STE A1106
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-4052
Practice Address - Country:US
Practice Address - Phone:616-977-9700
Practice Address - Fax:855-872-6489
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist