Provider Demographics
NPI:1093819229
Name:STATE OF MICHIGAN
Entity Type:Organization
Organization Name:STATE OF MICHIGAN
Other - Org Name:GRAND RAPIDS HOME FOR VETERANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-364-5355
Mailing Address - Street 1:3000 MONROE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3313
Mailing Address - Country:US
Mailing Address - Phone:616-364-5355
Mailing Address - Fax:616-364-5260
Practice Address - Street 1:3000 MONROE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3313
Practice Address - Country:US
Practice Address - Phone:616-364-5355
Practice Address - Fax:616-364-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010006663336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2353631OtherNABP NUMBER
MI5301000666OtherPHARMACY ID NUMBER