Provider Demographics
NPI:1518019850
Name:MYERS, THEODORE ALAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:ALAN
Last Name:MYERS
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 1:2428 ROCKHILL DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1239
Mailing Address - Country:US
Mailing Address - Phone:616-363-0962
Mailing Address - Fax:
Practice Address - Street 1:100 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4526
Practice Address - Country:US
Practice Address - Phone:616-965-8278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist