Provider Demographics
NPI:1720121429
Name:SPOELMA, ROSS THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:THOMAS
Last Name:SPOELMA
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 1:8255 SLEEPER AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-7506
Mailing Address - Country:US
Mailing Address - Phone:231-924-8784
Mailing Address - Fax:
Practice Address - Street 1:1035 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8794
Practice Address - Country:US
Practice Address - Phone:231-689-6677
Practice Address - Fax:231-689-3869
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302024469OtherR.PH.