Provider Demographics
NPI:1285963611
Name:GREAT LAKES RPH CORP
Entity type:Organization
Organization Name:GREAT LAKES RPH CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-672-7774
Mailing Address - Street 1:2500 E BELTLINE AVE SE
Mailing Address - Street 2:SUITE O
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5987
Mailing Address - Country:US
Mailing Address - Phone:616-949-4499
Mailing Address - Fax:616-949-9890
Practice Address - Street 1:2500 E BELTLINE AVE SE STE O
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5987
Practice Address - Country:US
Practice Address - Phone:616-949-4499
Practice Address - Fax:616-949-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010092593336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123017OtherPK
MI1030Medicare PIN
MI4464650002Medicare NSC