Provider Demographics
NPI:1750666749
Name:HAVERKAMJP, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:HAVERKAMJP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 BANTAM DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7526
Mailing Address - Country:US
Mailing Address - Phone:810-669-2002
Mailing Address - Fax:
Practice Address - Street 1:2829 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-1152
Practice Address - Country:US
Practice Address - Phone:616-248-9030
Practice Address - Fax:616-248-7968
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI028050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist