Provider Demographics
NPI:1164502803
Name:GREAT LAKES BAY HEALTH CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES BAY HEALTH CENTERS
Other - Org Name:GREAT LAKES BAY HEALTH CENTERS PHARMACY SAGINAW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-755-3633
Mailing Address - Street 1:501 LAPEER AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1203
Mailing Address - Country:US
Mailing Address - Phone:989-759-6400
Mailing Address - Fax:989-759-6423
Practice Address - Street 1:1522 JANES AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-1819
Practice Address - Country:US
Practice Address - Phone:989-755-3633
Practice Address - Fax:989-755-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010073753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045515OtherPK