1225688229 NPI number — GUARDIAN PHARMACY OF GRAND RAPIDS, LLC

Table of content: (NPI 1225688229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225688229 NPI number — GUARDIAN PHARMACY OF GRAND RAPIDS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF GRAND RAPIDS, LLC
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:
GUARDIAN PHARMACY OF MICHIGAN
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:
1225688229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 11407
Provider Second Line Business Mailing Address:
DEPT # 8130
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-8130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-389-1383
Provider Business Mailing Address Fax Number:
404-389-1384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2930 29TH ST SE
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:
49512-1723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-965-7480
Provider Business Practice Location Address Fax Number:
616-974-8205
Provider Enumeration Date:
09/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
STAUFFER
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
616-965-7480

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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