Provider Demographics
NPI:1821562844
Name:PADOGDOG, CATHERINE FORMALEJO
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:FORMALEJO
Last Name:PADOGDOG
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 1:1106 BURTON ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-1435
Mailing Address - Country:US
Mailing Address - Phone:616-245-2463
Mailing Address - Fax:
Practice Address - Street 1:2051 RIDGECREST RD SE APT 7
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4321
Practice Address - Country:US
Practice Address - Phone:616-322-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist