Provider Demographics
NPI:1508231176
Name:DOORNBOS, JUDITH (RPH)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:DOORNBOS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-6868
Mailing Address - Fax:
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-252-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist