Provider Demographics
NPI:1235257387
Name:CANCER AND HEMATOLOGY CENTERS OF WESTERN MI, P.C.
Entity Type:Organization
Organization Name:CANCER AND HEMATOLOGY CENTERS OF WESTERN MI, P.C.
Other - Org Name:CANCER & HEMATOLOGY CTRS OF WESTERN MI
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 1:145 MICHIGAN AVE NE
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-977-4840
Mailing Address - Fax:616-885-1459
Practice Address - Street 1:145 MICHIGAN AVE NE
Practice Address - Street 2:SUITE 3100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-977-4840
Practice Address - Fax:616-885-1459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010063263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3113438Medicaid
MI0M08620Medicare UPIN
MI3113438Medicaid