Provider Demographics
NPI:1023017456
Name:GREAT LAKES RPH
Entity Type:Organization
Organization Name:GREAT LAKES RPH
Other - Org Name:WEICK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-672-7774
Mailing Address - Street 1:71 124TH AVE
Mailing Address - Street 2:PO BOX 53
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-9772
Mailing Address - Country:US
Mailing Address - Phone:269-672-7774
Mailing Address - Fax:
Practice Address - Street 1:71 124TH AVE
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:MI
Practice Address - Zip Code:49344-9772
Practice Address - Country:US
Practice Address - Phone:269-672-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2343250OtherNCPDP #