Provider Demographics
NPI:1568818391
Name:MEIJER STORES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER STORES LIMITED PARTNERSHIP
Other - Org Name:MEIJER SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY MERCHANDISING
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
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:616-791-5274
Mailing Address - Fax:
Practice Address - Street 1:8455 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-1607
Practice Address - Country:US
Practice Address - Phone:734-391-2310
Practice Address - Fax:734-391-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010109333336S0011X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100057940Medicaid
MI1568818391Medicaid
IN201191560BMedicaid
IL381274536007Medicaid
KY7100418890Medicaid
OH0171765Medicaid
KY7100418890Medicaid