MEDICARE: MEIJER STORES LIMITED PARTNERSHIP

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	332B00000X	Durable Medical Equipment & Medical Supplies	02723850	OH
2	3336C0003X	Community/Retail Pharmacy	02723850	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114014362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEIJER STORES LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	2929 WALKER AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-9424
Country	:	US
Telephone Number	:	616-791-3169
Fax Number	:	616-735-8532

Provider Business Practice Location Address
First Line	:	1391 CONANT ST
Second Line	:
City	:	MAUMEE
State	:	OH
Zip	:	43537-1609
Country	:	US
Telephone Number	:	419-891-8710
Fax Number	:	419-891-8765

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY MANAGED CARE
Name	:	JASON BEAUCH
Credential	:	RPH
Telephone Number	:	616-791-3169

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	03/19/2014

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