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General NPI Number Information
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NPI Number | 1407042138
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Entity Type | Organization
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Legal Business Name | MEIJER GREAT LAKES LIMITED PARTNERSHIP
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Dates
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Enumeration Date | 09/17/2007
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Last Update Date | 05/30/2017
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Provider Practice Location Address
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Address Line | 2155 PAUL JONES WAY SUITE 100
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City | LEXINGTON
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State | KY
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Zip | 40509-2220
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Country | US
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Telephone | 859-264-3010
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Fax | 859-264-3065
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Provider Business Mailing Address
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Address Line | 2929 WALKER AVE NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-9424
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Country | US
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Telephone | 616-791-3169
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Fax | 616-735-8532
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Authorized Official
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Title or Position | DIRECTOR OF PHARMACY MANAGED CARE
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Name | MR. JASON BEAUCH
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Credential | RPH
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Telephone | 616-791-3169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | P06542
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | P06542
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License Number State | KY
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