Provider Demographics
NPI:1922058908
Name:DYKSTRA DRUG STORE
Entity Type:Organization
Organization Name:DYKSTRA DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:KLAASEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-392-8130
Mailing Address - Street 1:91 DOUGLAS AVE
Mailing Address - Street 2:PO BOX 8249
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2188
Mailing Address - Country:US
Mailing Address - Phone:616-392-8130
Mailing Address - Fax:616-392-8025
Practice Address - Street 1:91 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2188
Practice Address - Country:US
Practice Address - Phone:616-392-8130
Practice Address - Fax:616-392-8025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010012413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4294122Medicaid
MI2328587Medicaid
MI2328587OtherNCPDP
MI1285990001Medicare ID - Type Unspecified