1093819229 NPI number — STATE OF MICHIGAN

Table of content: (NPI 1093819229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093819229 NPI number — STATE OF MICHIGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF MICHIGAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRAND RAPIDS HOME FOR VETERANS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093819229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 MONROE AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49505-3313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-364-5355
Provider Business Mailing Address Fax Number:
616-364-5260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 MONROE AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49505-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-364-5355
Provider Business Practice Location Address Fax Number:
616-364-5260
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
616-364-5355

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  5301000666 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2353631 . This is a "NABP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5301000666 . This is a "PHARMACY ID NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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