Provider Demographics
NPI:1346650850
Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Other - Org Name:MEIJER PHARMACY #272
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY MANAGED CARE
Authorized Official - Prefix:MR
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 1:1676 WESTPARK DR.
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4712
Practice Address - Country:US
Practice Address - Phone:270-495-6710
Practice Address - Fax:270-495-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07629332B00000X, 3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100305600Medicaid
TN1346650850Medicaid
MI6507510031Medicare NSC
KYK075940Medicare PIN