MEDICARE: MEIJER GREAT LAKES 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	054015246	IL
2	3336C0003X	Community/Retail Pharmacy	054015246	IL

General Provider Information

NPI Number	:	1780954586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEIJER GREAT LAKES 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	:	1301 MEIJER DR
Second Line	:
City	:	ROLLING MEADOWS
State	:	IL
Zip	:	60008-4205
Country	:	US
Telephone Number	:	847-690-1210
Fax Number	:	847-690-0265

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

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	02/25/2021

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