MEDICARE: SAINT MARYS FAMILY PHARMACY

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	5301004226	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2045998	OTHER	PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679519581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT MARYS FAMILY PHARMACY

Provider Business Mailing Address
First Line	:	360 DIVISION AVE S
Second Line	:	STE 1A
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4501
Country	:	US
Telephone Number	:	616-685-1147
Fax Number	:	616-685-1145

Provider Business Practice Location Address
First Line	:	360 DIVISION AVE S
Second Line	:	STE 1A
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4501
Country	:	US
Telephone Number	:	616-685-1147
Fax Number	:	616-685-1145

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ROBERT CASALOU
Credential	:
Telephone Number	:	734-712-3792

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	09/26/2022

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Directions to “SAINT MARYS FAMILY PHARMACY ” Practice Location

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