Healthcare Provider Details

I. General information

NPI: 1942629639
Provider Name (Legal Business Name): MEIJER STORES LIMITED PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DAN JONES RD.
PLAINFIELD IN
46168-1791
US

IV. Provider business mailing address

2929 WALKER AVE NW
GRAND RAPIDS MI
49544-6402
US

V. Phone/Fax

Practice location:
  • Phone: 317-204-1310
  • Fax: 317-204-1365
Mailing address:
  • Phone: 616-791-3169
  • Fax: 616-735-8532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number60006371
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006371
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier201219630A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

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