MEDICARE: GREAT LAKES RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2343250	OTHER	MI	NCPDP #

General Provider Information

NPI Number	:	1023017456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES RPH

Provider Business Mailing Address
First Line	:	71 124TH AVE
Second Line	:	PO BOX 53
City	:	SHELBYVILLE
State	:	MI
Zip	:	49344-9772
Country	:	US
Telephone Number	:	269-672-7774
Fax Number	:

Provider Business Practice Location Address
First Line	:	71 124TH AVE
Second Line	:
City	:	SHELBYVILLE
State	:	MI
Zip	:	49344-9772
Country	:	US
Telephone Number	:	269-672-7774
Fax Number	:

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	12/17/2024

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Practice Location Address:

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49344

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Directions to “GREAT LAKES RPH ” Practice Location

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