Healthcare Provider Details

I. General information

NPI: 1023017456
Provider Name (Legal Business Name): GREAT LAKES RPH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 124TH AVE
SHELBYVILLE MI
49344-9772
US

IV. Provider business mailing address

71 124TH AVE PO BOX 53
SHELBYVILLE MI
49344-9772
US

V. Phone/Fax

Practice location:
  • Phone: 269-672-7774
  • Fax:
Mailing address:
  • Phone: 269-672-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL A HOLTZ
Title or Position: PHARMACIST/OWNER
Credential: R.PH.
Phone: 269-672-7774