Provider Demographics
NPI:1649327990
Name:RELLIM INCORPORATED
Entity type:Organization
Organization Name:RELLIM INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-622-3392
Mailing Address - Street 1:PO BOX 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9830
Mailing Address - Country:US
Mailing Address - Phone:877-540-4748
Mailing Address - Fax:801-716-4872
Practice Address - Street 1:204 S BRIDGE ST
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-1527
Practice Address - Country:US
Practice Address - Phone:517-622-3392
Practice Address - Fax:517-622-5138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010073413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2359378OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI2359378Medicaid