Provider Demographics
NPI:1235226424
Name:FAMILY PHARMACY-SW CAMPUS
Entity Type:Organization
Organization Name:FAMILY PHARMACY-SW CAMPUS
Other - Org Name:MERCY HEALTH PHARMACY-SOUTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CASALOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-712-3792
Mailing Address - Street 1:2373 64TH ST SW
Mailing Address - Street 2:STE 1100
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-7974
Mailing Address - Country:US
Mailing Address - Phone:616-685-3950
Mailing Address - Fax:616-249-0850
Practice Address - Street 1:2373 64TH ST SW
Practice Address - Street 2:STE 1100
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-7974
Practice Address - Country:US
Practice Address - Phone:616-685-3950
Practice Address - Fax:616-249-0850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010084863336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042398OtherPK
MI4110913Medicaid
MI1235226424Medicaid