MEDICARE: MEIJER STORES LIMITED PARTNERSHIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1669234878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEIJER STORES LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	2929 WALKER AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-6402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 NORTH MAIN STREET
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720
Country	:	US
Telephone Number	:	234-236-2610
Fax Number	:	234-236-2625

Authorized Official
Title or Position	:	DIRECTOR OF MANAGED CARE PROGRAMS
Name	:	JOSEPH BACK
Credential	:
Telephone Number	:	616-791-3346

Provider Enumeration Date	:	01/24/2024
Last Update Date	:	01/24/2024

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