Provider Demographics
NPI:1164883450
Name:MEIJER STORES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER STORES LIMITED PARTNERSHIP
Other - Org Name:MEIJER PHARMACY #287
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY MERCHANDISING
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-791-3169
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:616-791-3169
Mailing Address - Fax:616-735-8532
Practice Address - Street 1:2622 MENARDS DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8075
Practice Address - Country:US
Practice Address - Phone:812-647-2210
Practice Address - Fax:812-647-2165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006565A332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201164000BMedicaid
KY7100400710Medicaid
KY7100400710Medicaid
IN6685160083Medicare NSC