Provider Demographics
NPI:1811597339
Name:LATHAM, BETHANY (PHARMD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LATHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 US 31
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8390
Mailing Address - Country:US
Mailing Address - Phone:616-844-4184
Mailing Address - Fax:
Practice Address - Street 1:14700 US 31
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8390
Practice Address - Country:US
Practice Address - Phone:616-844-4184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist