Provider Demographics
NPI:1336383249
Name:SMITH, DAVID ROSS (RPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ROSS
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 EASTERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3234
Mailing Address - Country:US
Mailing Address - Phone:616-247-0440
Mailing Address - Fax:616-347-0591
Practice Address - Street 1:2027 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3234
Practice Address - Country:US
Practice Address - Phone:616-247-0440
Practice Address - Fax:616-347-0591
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist