Provider Demographics
NPI:1902806755
Name:DEYOUNG, GERALD ROBERT
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ROBERT
Last Name:DEYOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:DEYOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:200 JEFFERSON AVE SE
Mailing Address - Street 2:ADVANTAGE HEALTH PHYSICIANS AND ST. MARY'S HEALTH CARE
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4502
Mailing Address - Country:US
Mailing Address - Phone:616-752-6410
Mailing Address - Fax:
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:ADVANTAGE HEALTH PHYSICIANS AND ST. MARY'S HEALTH CARE
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-752-6410
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020272491835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy