MEDICARE: TRUCARE LTC, LLC

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	3336C0003X	Community/Retail Pharmacy
2	3336L0003X	Long Term Care Pharmacy	5301010899	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2155947	OTHER		PK

General Provider Information

NPI Number	:	1114384559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRUCARE LTC, LLC

Provider Business Mailing Address
First Line	:	6140 28TH ST SE STE 105
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6938
Country	:	US
Telephone Number	:	616-965-7480
Fax Number	:	616-974-8205

Provider Business Practice Location Address
First Line	:	6140 28TH ST SE STE 105
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6938
Country	:	US
Telephone Number	:	616-965-7480
Fax Number	:	616-974-8205

Authorized Official
Title or Position	:	PHARMACY PRESIDENT
Name	:	MICHAEL HOLTZ
Credential	:
Telephone Number	:	269-998-6772

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	07/05/2016

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