Provider Demographics
NPI:1558478610
Name:KENTWOOD PHARMACY
Entity type:Organization
Organization Name:KENTWOOD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MULDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-827-9100
Mailing Address - Street 1:6680 KALAMAZOO AVENUE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-554-1964
Mailing Address - Fax:616-554-3140
Practice Address - Street 1:6680 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7030
Practice Address - Country:US
Practice Address - Phone:616-554-1964
Practice Address - Fax:616-554-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200288790Medicaid
MI2362349Medicaid
IN200288790Medicaid