MEDICARE: GREAT LAKES R.PH. CORP

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		MI
2	333600000X	Pharmacy	5301007296	MI
3	3336C0003X	Community/Retail Pharmacy	5301007296	MI

General Provider Information

NPI Number	:	1902970668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES R.PH. CORP

Provider Business Mailing Address
First Line	:	71 124TH AVE
Second Line	:	PO BOX 53
City	:	SHELBYVILLE
State	:	MI
Zip	:	49344-9772
Country	:	US
Telephone Number	:	269-672-7774
Fax Number	:	269-672-7887

Provider Business Practice Location Address
First Line	:	71 124TH AVE
Second Line	:
City	:	SHELBYVILLE
State	:	MI
Zip	:	49344
Country	:	US
Telephone Number	:	269-672-7774
Fax Number	:	269-672-7887

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL A HOLTZ
Credential	:
Telephone Number	:	269-792-3790

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	12/16/2019

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