Provider Demographics
NPI:1457393027
Name:ST MARYS FAMILY PHCY SUNSET
Entity type:Organization
Organization Name:ST MARYS FAMILY PHCY SUNSET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-913-1115
Mailing Address - Street 1:725 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-7945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-7945
Practice Address - Country:US
Practice Address - Phone:616-457-7281
Practice Address - Fax:616-457-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006892333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2352689OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI4111536Medicaid