Provider Demographics
NPI:1386054633
Name:MIKITA, JIM JOHN (RPH)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:JOHN
Last Name:MIKITA
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 1:4146 E GABLES CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9378
Mailing Address - Country:US
Mailing Address - Phone:616-656-6110
Mailing Address - Fax:
Practice Address - Street 1:1801 MARKETPLACE DR SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8506
Practice Address - Country:US
Practice Address - Phone:616-656-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020224131835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy