Provider Demographics
NPI:1942664503
Name:MEIJER STORES LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MEIJER STORES LIMITED PARTNERSHIP
Other - Org Name:MEIJER PHARMACY #276
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:
Mailing Address - Fax:
Practice Address - Street 1:801 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7816
Practice Address - Country:US
Practice Address - Phone:262-899-6010
Practice Address - Fax:262-899-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100057519Medicaid
WIK300218943Medicare PIN
WI6685160085Medicare NSC