=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750826525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEIJER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2017
-----------------------------------------------------
Last Update Date | 03/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1138 W 3 MILE RD
-----------------------------------------------------
City | SAULT SAINTE MARIE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49783-9132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-253-2810
-----------------------------------------------------
Fax | 906-253-2865
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2929 WALKER AVE NW ATTN: MANAGED CARE GOVERNMENT PROGRAMS
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49544-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-791-3169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF PHARMACY MERCHANDISING
-----------------------------------------------------
Name | JASON BEAUCH
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 616-791-3169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------