MEDICARE: WESTSIDE PHARMACY, INC

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	333600000X	Pharmacy	5301005171	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2317849	OTHER		NCPDP

General Provider Information

NPI Number	:	1346242666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTSIDE PHARMACY, INC

Provider Business Mailing Address
First Line	:	632 N DIBBLE BVD
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917
Country	:	US
Telephone Number	:	517-323-2382
Fax Number	:	517-323-0459

Provider Business Practice Location Address
First Line	:	632 N DIBBLE BVD
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917
Country	:	US
Telephone Number	:	517-323-2382
Fax Number	:	517-323-0459

Authorized Official
Title or Position	:	PRESIDENT/TREASURER
Name	:	MR. GREGORY S BOVEE
Credential	:	RPH
Telephone Number	:	517-323-2382

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	08/22/2020

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Directions to “WESTSIDE PHARMACY, INC ” Practice Location

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