Provider Demographics
NPI:1417542614
Name:MACDONALD, RYAN LEE (CPHT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:LEE
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10772 W CARSON CITY RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9141
Mailing Address - Country:US
Mailing Address - Phone:616-754-5203
Mailing Address - Fax:
Practice Address - Street 1:10772 W CARSON CITY RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9141
Practice Address - Country:US
Practice Address - Phone:616-754-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303033945183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician