Provider Demographics
NPI:1114428729
Name:MEIJER, INC.
Entity Type:Organization
Organization Name:MEIJER, INC.
Other - Org Name:MEIJER PHARMACY #254
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-791-5032
Mailing Address - Street 1:2929 WALKER AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-6402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4075 32ND AVE
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426
Practice Address - Country:US
Practice Address - Phone:616-229-9310
Practice Address - Fax:616-229-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114428729Medicaid