Healthcare Provider Details

I. General information

NPI: 1285963611
Provider Name (Legal Business Name): GREAT LAKES RPH CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E BELTLINE AVE SE STE O
GRAND RAPIDS MI
49546-5987
US

IV. Provider business mailing address

2500 E BELTLINE AVE SE SUITE O
GRAND RAPIDS MI
49546-5987
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4499
  • Fax: 616-949-9890
Mailing address:
  • Phone: 616-949-4499
  • Fax: 616-949-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009259
License Number StateMI

VIII. Authorized Official

Name: MICHAEL HOLTZ
Title or Position: PHARMACIST
Credential:
Phone: 269-672-7774