Healthcare Provider Details

I. General information

NPI: 1720272016
Provider Name (Legal Business Name): GREAT LAKES COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 SHELDON RD 104A
GRAND HAVEN MI
49417-2480
US

IV. Provider business mailing address

1445 SHELDON RD 104A
GRAND HAVEN MI
49417-2480
US

V. Phone/Fax

Practice location:
  • Phone: 616-842-1223
  • Fax: 616-842-0930
Mailing address:
  • Phone: 616-842-5193
  • Fax: 616-842-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008607
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DARCY TUSSING
Title or Position: DIR OF PHRM
Credential: RPH
Phone: 616-847-5230