Provider Demographics
NPI:1902970668
Name:GREAT LAKES R.PH. CORP
Entity type:Organization
Organization Name:GREAT LAKES R.PH. CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-792-3790
Mailing Address - Street 1:71 124TH AVE
Mailing Address - Street 2:PO BOX 53
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-9772
Mailing Address - Country:US
Mailing Address - Phone:269-672-7774
Mailing Address - Fax:269-672-7887
Practice Address - Street 1:71 124TH AVE
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:MI
Practice Address - Zip Code:49344
Practice Address - Country:US
Practice Address - Phone:269-672-7774
Practice Address - Fax:269-672-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
MI5301007296333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Z30019OtherBCBS VACCINATION PROVIDER
MI0Z31051OtherBCBSMI DME PROVIDER PIN
MI0Z30019OtherBCBS VACCINATION PROVIDER
MI0Z31051OtherBCBSMI DME PROVIDER PIN
MIMI1030Medicare PIN