Provider Demographics
NPI:1730159021
Name:RIDDER, TRACY LYN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYN
Last Name:RIDDER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4591 CREEK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1905
Mailing Address - Country:US
Mailing Address - Phone:616-881-2419
Mailing Address - Fax:
Practice Address - Street 1:3960 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2420
Practice Address - Country:US
Practice Address - Phone:616-534-9649
Practice Address - Fax:616-538-6730
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist