1568818391 NPI number — MEIJER STORES LIMITED PARTNERSHIP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568818391 NPI number — MEIJER STORES LIMITED PARTNERSHIP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEIJER STORES 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:
1568818391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2017
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:
616-791-5274
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8455 HAGGERTY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48111-1607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-391-2310
Provider Business Practice Location Address Fax Number:
734-391-2365
Provider Enumeration Date:
05/11/2016

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X , with the licence number:  5301010933 , 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: 100057940 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1568818391 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201191560B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 381274536007 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100418890 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0171765 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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