Provider Demographics
NPI:1497033732
Name:BOAHBEDASON, MICHELLE LYNN
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:BOAHBEDASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3191 28TH ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1110
Mailing Address - Country:US
Mailing Address - Phone:616-534-5533
Mailing Address - Fax:
Practice Address - Street 1:4252 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3607
Practice Address - Country:US
Practice Address - Phone:616-281-1323
Practice Address - Fax:616-281-1330
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist