Provider Demographics
NPI:1700102993
Name:MIDTOWNE PHARMACY
Entity type:Organization
Organization Name:MIDTOWNE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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 1:555 MIDTOWNE ST NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5729
Mailing Address - Country:US
Mailing Address - Phone:616-554-1964
Mailing Address - Fax:
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5729
Practice Address - Country:US
Practice Address - Phone:616-554-1964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010092983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy