Provider Demographics
NPI:1013049584
Name:WITHAM, ROBERT B (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:B
Last Name:WITHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 THORNAPPLE RIVER DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9138
Mailing Address - Country:US
Mailing Address - Phone:616-949-1325
Mailing Address - Fax:
Practice Address - Street 1:5859 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6905
Practice Address - Country:US
Practice Address - Phone:616-949-9892
Practice Address - Fax:616-949-5709
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist