Provider Demographics
NPI:1225253974
Name:CANCER & HEMATOLOGY CENTERS OF WESTERN MI, P.C.
Entity Type:Organization
Organization Name:CANCER & HEMATOLOGY CENTERS OF WESTERN MI, P.C.
Other - Org Name:CHCWM ST. MARY'S
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MELGAREJO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:616-977-4850
Mailing Address - Street 1:250 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4608
Mailing Address - Country:US
Mailing Address - Phone:616-685-5257
Mailing Address - Fax:616-685-5534
Practice Address - Street 1:250 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4608
Practice Address - Country:US
Practice Address - Phone:616-685-5257
Practice Address - Fax:616-685-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010080643336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225253974Medicaid
5316140004Medicare NSC
5316140004Medicare NSC