Provider Demographics
NPI:1205223070
Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Other - Org Name:MEIJER PHARMACY #192
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY MANAGED CARE
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 1:2013 MCFARLAND ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6835
Practice Address - Country:US
Practice Address - Phone:815-721-8610
Practice Address - Fax:815-721-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054019347332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========025Medicaid
ILIL7525Medicare PIN
IL=========025Medicaid