Provider Demographics
NPI:1508117615
Name:DORNBOS, TED EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:EDWARD
Last Name:DORNBOS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2748
Mailing Address - Country:US
Mailing Address - Phone:269-382-4399
Mailing Address - Fax:269-382-1719
Practice Address - Street 1:400 HOWARD ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2748
Practice Address - Country:US
Practice Address - Phone:269-382-4399
Practice Address - Fax:269-382-1719
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist