Provider Demographics
NPI:1679519581
Name:SAINT MARYS FAMILY PHARMACY
Entity Type:Organization
Organization Name:SAINT MARYS FAMILY PHARMACY
Other - Org Name:TRINITY HEALTH PHARMACY - CATHEDRAL SQUARE
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 1:360 DIVISION AVE S
Mailing Address - Street 2:STE 1A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4501
Mailing Address - Country:US
Mailing Address - Phone:616-685-1147
Mailing Address - Fax:616-685-1145
Practice Address - Street 1:360 DIVISION AVE S
Practice Address - Street 2:STE 1A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4501
Practice Address - Country:US
Practice Address - Phone:616-685-1147
Practice Address - Fax:616-685-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010042263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045998OtherPK
MI1679519581Medicaid
MI4825146Medicaid