Provider Demographics
NPI:1720272016
Name:GREAT LAKES COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:GREAT LAKES COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHRM
Authorized Official - Prefix:
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUSSING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-847-5230
Mailing Address - Street 1:1445 SHELDON RD
Mailing Address - Street 2:104A
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2480
Mailing Address - Country:US
Mailing Address - Phone:616-842-5193
Mailing Address - Fax:616-842-0930
Practice Address - Street 1:1445 SHELDON RD
Practice Address - Street 2:104A
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2480
Practice Address - Country:US
Practice Address - Phone:616-842-1223
Practice Address - Fax:616-842-0930
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYNANON, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-30
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010086073336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2369658OtherOTHER ID NUMBER