Provider Demographics
NPI:1104214014
Name:WEST MICHIGAN PHARMACY LLC
Entity Type:Organization
Organization Name:WEST MICHIGAN PHARMACY LLC
Other - Org Name:WEST MICHIGAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY MGR,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:231-305-4095
Mailing Address - Street 1:20095 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2365
Mailing Address - Country:US
Mailing Address - Phone:231-305-4095
Mailing Address - Fax:231-305-4094
Practice Address - Street 1:20095 GILBERT RD
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2365
Practice Address - Country:US
Practice Address - Phone:231-305-4095
Practice Address - Fax:231-305-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010107153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149514OtherPK