Healthcare Provider Details

I. General information

NPI: 1548650146
Provider Name (Legal Business Name): MEIJER GREAT LAKES LTD PT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12821 CROSS OVER DR
DEWITT MI
48820-7993
US

IV. Provider business mailing address

12821 CROSS OVER DR
DEWITT MI
48820-7993
US

V. Phone/Fax

Practice location:
  • Phone: 517-669-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5302040403
License Number StateMI

VIII. Authorized Official

Name: ELIZABETH LINDER
Title or Position: PHARMACY SPECIALIST
Credential:
Phone: 517-391-5807