Provider Demographics
NPI:1891159455
Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER GREAT LAKES LIMITED PARTNERSHIP
Other - Org Name:MEIJER PHARMACY #289
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: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:49544-6402
Mailing Address - Country:US
Mailing Address - Phone:616-791-3169
Mailing Address - Fax:616-793-5853
Practice Address - Street 1:750 E ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1340
Practice Address - Country:US
Practice Address - Phone:847-210-0810
Practice Address - Fax:847-201-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========027Medicaid
IL6507510037Medicare NSC
ILIL7525Medicare PIN