Provider Demographics
NPI:1194490557
Name:BOLDT, DANIEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:BOLDT
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 1:12177 MILLPOND DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-9599
Mailing Address - Country:US
Mailing Address - Phone:616-560-7965
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-6383
Practice Address - Fax:616-685-3057
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020389301835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care