1134556277 NPI number — MEIJER GREAT LAKES LIMITED PARTNERSHIP

Table of content: (NPI 1134556277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134556277 NPI number — MEIJER GREAT LAKES LIMITED PARTNERSHIP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEIJER GREAT LAKES LIMITED PARTNERSHIP
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:
Provider Other Organization Name Type Code:
6
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:
1134556277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2929 WALKER AVE NW
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:
49544-6402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-791-3169
Provider Business Mailing Address Fax Number:
616-735-8532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3649 N. VERMILION ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61832-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-655-7210
Provider Business Practice Location Address Fax Number:
217-655-7265
Provider Enumeration Date:
10/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BEAUCH
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY MANAGED CARE
Authorized Official Telephone Number:
616-791-3169

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  054018334 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054018334 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201204100A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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