Provider Demographics
NPI:1528338332
Name:MEIJER STORES LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:MEIJER STORES LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-791-3169
Mailing Address - Street 1:2929 WALKER AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-6402
Mailing Address - Country:US
Mailing Address - Phone:616-791-3169
Mailing Address - Fax:616-735-8532
Practice Address - Street 1:5150 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7878
Practice Address - Country:US
Practice Address - Phone:219-877-2410
Practice Address - Fax:219-877-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60004967332B00000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201079310AMedicaid
MI1528338332Medicaid
INM300060375Medicare PIN
IN6685160015Medicare NSC