Provider Demographics
NPI:1013512946
Name:REDELINGHUYS, JUANITA CORNELIA
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:CORNELIA
Last Name:REDELINGHUYS
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 1:306 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1166
Mailing Address - Country:US
Mailing Address - Phone:248-453-5415
Mailing Address - Fax:
Practice Address - Street 1:21777 21 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-2962
Practice Address - Country:US
Practice Address - Phone:586-949-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist