Provider Demographics
NPI:1689964876
Name:ELTZROTH, GERALD W JR (RPH)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:W
Last Name:ELTZROTH
Suffix:JR
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 1:507 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1166
Mailing Address - Country:US
Mailing Address - Phone:616-754-3625
Mailing Address - Fax:
Practice Address - Street 1:507 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1166
Practice Address - Country:US
Practice Address - Phone:616-754-3625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist