Healthcare Provider Details

I. General information

NPI: 1588641682
Provider Name (Legal Business Name): SAINT MARYS FAMILY PHARMACY-WEGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4650
US

IV. Provider business mailing address

300 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4650
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6105
  • Fax: 616-685-8981
Mailing address:
  • Phone: 616-685-6105
  • Fax: 616-685-8981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301006807
License Number StateMI

VIII. Authorized Official

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