Healthcare Provider Details

I. General information

NPI: 1710908108
Provider Name (Legal Business Name): MEIJER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 M-89
PLAINWELL MI
49080
US

IV. Provider business mailing address

2929 WALKER AVE NW
GRAND RAPIDS MI
49544-9424
US

V. Phone/Fax

Practice location:
  • Phone: 269-685-3810
  • Fax: 269-685-3765
Mailing address:
  • Phone: 616-791-3169
  • Fax: 616-735-8532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5301007120
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301007120
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2360749
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer

VIII. Authorized Official

Name: JASON BEAUCH
Title or Position: DIRECTOR OF PHARMACY MANAGED CARE
Credential: RPH
Phone: 616-791-3169