Provider Demographics
NPI:1124667258
Name:BEACH, GRANT LAWSON
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:LAWSON
Last Name:BEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MICHIGAN ST NW APT 910
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2330
Mailing Address - Country:US
Mailing Address - Phone:616-824-6200
Mailing Address - Fax:
Practice Address - Street 1:201 MICHIGAN ST NW APT 910
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2330
Practice Address - Country:US
Practice Address - Phone:616-824-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351010562183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB200288488123OtherDRIVERS LICENSE