Provider Demographics
NPI:1730634429
Name:BROEKHUIZEN, TIMOTHY EDWARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:BROEKHUIZEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 KENOWA AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9523
Mailing Address - Country:US
Mailing Address - Phone:616-667-9713
Mailing Address - Fax:616-667-9715
Practice Address - Street 1:4542 KENOWA AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-9523
Practice Address - Country:US
Practice Address - Phone:616-667-9713
Practice Address - Fax:616-667-9715
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302040726OtherSTATE BOARD OF PHARMACY REGISTERED PHARMACIST LICENSE