Provider Demographics
NPI:1306322458
Name:CRADDOCK, KAITLYN (PHARMD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:CRADDOCK
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 1:665 SEWARD AVE NW STE 320
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5190
Mailing Address - Country:US
Mailing Address - Phone:616-267-7029
Mailing Address - Fax:616-391-9085
Practice Address - Street 1:588 E LAKEWOOD BLVD FL 2
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2023
Practice Address - Country:US
Practice Address - Phone:616-494-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020467461835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care