Provider Demographics
NPI:1417406406
Name:DEBOER, MIA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MIA
Middle Name:
Last Name:DEBOER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:BELLEFEUILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1225 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5510
Practice Address - Country:US
Practice Address - Phone:616-454-8368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-01
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041264183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist