Provider Demographics
NPI:1588641682
Name:SAINT MARYS FAMILY PHARMACY-WEGE CENTER
Entity Type:Organization
Organization Name:SAINT MARYS FAMILY PHARMACY-WEGE CENTER
Other - Org Name:MERCY HEALTH PHARMACY - WEGE CENTER
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 1:300 LAFAYETTE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4650
Mailing Address - Country:US
Mailing Address - Phone:616-685-6105
Mailing Address - Fax:616-685-8981
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4650
Practice Address - Country:US
Practice Address - Phone:616-685-6105
Practice Address - Fax:616-685-8981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010068073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4989440001Medicare NSC