Provider Demographics
NPI:1790971380
Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Other - Org Name:MEIJER PHARMACY #162
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:49544-9424
Mailing Address - Country:US
Mailing Address - Phone:616-791-3169
Mailing Address - Fax:616-735-8532
Practice Address - Street 1:9905 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-3943
Practice Address - Country:US
Practice Address - Phone:502-995-2110
Practice Address - Fax:502-995-2165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP06543332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201191680AMedicaid
KY7100211650Medicaid
KYK075940Medicare PIN
IN201191680AMedicaid