Provider Demographics
NPI:1992214720
Name:REIDENBACH, MOLLIE MAE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MOLLIE
Middle Name:MAE
Last Name:REIDENBACH
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 1:1485 HIDDEN VALLEY DR SE APT 11
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6483
Mailing Address - Country:US
Mailing Address - Phone:231-690-3168
Mailing Address - Fax:
Practice Address - Street 1:850 76TH ST SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8510
Practice Address - Country:US
Practice Address - Phone:616-878-8009
Practice Address - Fax:616-878-8850
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist