Provider Demographics
NPI:1558073056
Name:GUARDIAN PHARMACY OF GRAND RAPIDS, LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF GRAND RAPIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-446-4018
Mailing Address - Street 1:10381 CITATION DR STE 500
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-6527
Mailing Address - Country:US
Mailing Address - Phone:810-626-5880
Mailing Address - Fax:810-626-5881
Practice Address - Street 1:10381 CITATION DR STE 500
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-6527
Practice Address - Country:US
Practice Address - Phone:810-626-5880
Practice Address - Fax:810-626-5881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301013032OtherMI BOP LICENSE