Provider Demographics
NPI:1306175468
Name:DEBOER, MICHAEL ROBERT
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:DEBOER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3876 E PARIS AVE SE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-3974
Mailing Address - Country:US
Mailing Address - Phone:616-977-9700
Mailing Address - Fax:616-855-0937
Practice Address - Street 1:3876 E PARIS AVE SE
Practice Address - Street 2:SUITE 13
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-3974
Practice Address - Country:US
Practice Address - Phone:616-977-9700
Practice Address - Fax:616-855-0937
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist