Provider Demographics
NPI:1952164634
Name:WIERENGA, ANNE (RPH)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:WIERENGA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-1596
Mailing Address - Country:US
Mailing Address - Phone:616-399-4100
Mailing Address - Fax:616-399-9645
Practice Address - Street 1:993 BUTTERNUT DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1596
Practice Address - Country:US
Practice Address - Phone:616-399-4100
Practice Address - Fax:616-399-9645
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI5302025885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302025885Medicaid