Provider Demographics
NPI:1912473844
Name:KING, ADAM MATHEW (CPHT, PRS)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:MATHEW
Last Name:KING
Suffix:
Gender:M
Credentials:CPHT, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E BELTLINE AVE SE STE 175
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4362
Mailing Address - Country:US
Mailing Address - Phone:616-575-0211
Mailing Address - Fax:
Practice Address - Street 1:1550 E BELTLINE AVE SE STE 175
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4362
Practice Address - Country:US
Practice Address - Phone:616-575-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
MI5303000545183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI490107010039286OtherPHARMACY TECHNICAN CERTIFICATION BOARD
MI5303000545OtherMICHIGAN BOARD OF PHARMACY