Healthcare Provider Details

I. General information

NPI: 1710257514
Provider Name (Legal Business Name): MEIJER STORES LIMITED PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 STATE ROAD 26 E
LAFAYETTE IN
47905-4611
US

IV. Provider business mailing address

2929 WALKER AVE NW
GRAND RAPIDS MI
49544-6402
US

V. Phone/Fax

Practice location:
  • Phone: 765-449-9210
  • Fax: 765-449-9265
Mailing address:
  • Phone: 616-791-3169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number60004823
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60004823
License Number StateIN

VIII. Authorized Official

Name: JASON BEAUCH
Title or Position: DIRECTOR OF PHARMACY MANAGED CARE
Credential: RPH
Phone: 616-791-3169