Healthcare Provider Details

I. General information

NPI: 1679519581
Provider Name (Legal Business Name): SAINT MARYS FAMILY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 DIVISION AVE S STE 1A
GRAND RAPIDS MI
49503-4501
US

IV. Provider business mailing address

360 DIVISION AVE S STE 1A
GRAND RAPIDS MI
49503-4501
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-1147
  • Fax: 616-685-1145
Mailing address:
  • Phone: 616-685-1147
  • Fax: 616-685-1145

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 Number5301004226
License Number StateMI

VIII. Authorized Official

Name: ROBERT CASALOU
Title or Position: PRESIDENT/CEO
Credential:
Phone: 734-712-3792