Provider Demographics
NPI:1639455736
Name:MITIDIERI, JOSEPH A (RPH)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:MITIDIERI
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 1:5464 DISCOVERY DR SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6650
Mailing Address - Country:US
Mailing Address - Phone:616-292-2216
Mailing Address - Fax:
Practice Address - Street 1:6020 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7018
Practice Address - Country:US
Practice Address - Phone:616-698-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist