Provider Demographics
NPI:1417236514
Name:DERIDDER, KEVIN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:DERIDDER
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 1:4166 17 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-9451
Mailing Address - Country:US
Mailing Address - Phone:616-696-9040
Mailing Address - Fax:
Practice Address - Street 1:4166 17 MILE RD NE
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-9451
Practice Address - Country:US
Practice Address - Phone:616-696-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36072183500000X
MI5302038129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist