=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093819229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF MICHIGAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2006
-----------------------------------------------------
Last Update Date | 02/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2950 MONROE AVE NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49505-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-364-5355
-----------------------------------------------------
Fax | 517-275-7144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2950 MONROE AVE NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49505-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-364-5355
-----------------------------------------------------
Fax | 517-275-7144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LOUIS CIARAMELLO III
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 616-364-5355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 5301000666
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------