Provider Demographics
NPI:1407522162
Name:ISHIMWE, OLIVIER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIER
Middle Name:
Last Name:ISHIMWE
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 1:411 BRIAR LN NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2120
Mailing Address - Country:US
Mailing Address - Phone:574-302-6066
Mailing Address - Fax:
Practice Address - Street 1:3106 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4712
Practice Address - Country:US
Practice Address - Phone:517-337-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist