Provider Demographics
NPI:1992295190
Name:DILLARD, BRITTANY NICOLE
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:NICOLE
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
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:
Practice Address - Street 1:4600 BRETON RD SE STE 102
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5220
Practice Address - Country:US
Practice Address - Phone:616-391-9705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020425571835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty