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	9313	WI
2	3336C0003X	Community/Retail Pharmacy	9313	WI

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

General Provider Information

NPI Number	:	1639564578
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	:	49544-6402
Country	:	US
Telephone Number	:	616-791-3169
Fax Number	:	616-735-8532

Provider Business Practice Location Address
First Line	:	7701 GREEN BAY RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-4043
Country	:	US
Telephone Number	:	262-612-1610
Fax Number	:	262-612-1665

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

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	07/09/2015

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