Provider Demographics
NPI:1821428111
Name:DEJONGE, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:DEJONGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9753
Mailing Address - Country:US
Mailing Address - Phone:616-667-2033
Mailing Address - Fax:616-667-2065
Practice Address - Street 1:550 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9753
Practice Address - Country:US
Practice Address - Phone:616-667-2033
Practice Address - Fax:616-667-2065
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist