Provider Demographics
NPI:1922309194
Name:DETTLOFF, RICK W (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:W
Last Name:DETTLOFF
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 CRESCENDA DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9481
Mailing Address - Country:US
Mailing Address - Phone:616-690-6510
Mailing Address - Fax:
Practice Address - Street 1:7040 CRESCENDA DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9481
Practice Address - Country:US
Practice Address - Phone:616-690-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020264321835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy