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Provider Information for 1134556277


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MEIJER GREAT LAKES LIMITED PARTNERSHIP

Other Names:  
Doing Business As: 
MEIJER PHARMACY #269

Organization Subpart: NO

NPI: 1134556277
Last Updated: 2014-03-25
Certification Date:

Details

NameValue
NPI1134556277
Enumeration Date2013-10-03
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: Mr. JASON BEAUCH R.Ph
Title: Director of Pharmacy Managed Care
Phone: 6167913169
Mailing Address 2929 WALKER AVE NW
GRAND RAPIDS, MI 49544-6402
United States

Phone: 616-791-3169 | Fax:616-735-8532
 
Primary Practice Address 3649 N. VERMILION ST.
DANVILLE, IL 61832-1312
United States

Phone: 217-655-7210 | Fax:217-655-7265
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDIL201204100A
MEDICAIDIL=========021
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 332B00000X - Durable Medical Equipment & Medical Supplies IL054018334
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyIL054018334