NPIMap

Organization Active NPI

Meijer Great Lakes Limited Partnership

Doing business as Meijer Pharmacy #176

  • Community/Retail Pharmacy
  • Springfield, IL
National Provider Identifier
1013287853
Registry record updated Mar 24, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
054014283 Issued in IL
Legal business name
MEIJER GREAT LAKES LIMITED PARTNERSHIP
Doing business as
Meijer Pharmacy #176
Practice address
4200 Conestoga Dr
Springfield, IL 62711-7962
Phone
(217) 547-2410
Fax
(217) 547-2465
NPI assigned
Jan 11, 2012
Last updated
Mar 24, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 24, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jason Beauch, RPHNPI 1518380062
Title
Director of Pharmacy Managed Care
Phone
(616) 791-3169

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X 054014283 IL
Community/Retail Pharmacy 3336C0003X 054014283 IL Primary

Addresses

Primary practice location

4200 Conestoga Dr
Springfield, IL 62711-7962

Mailing address

2929 Walker Ave NW
Grand Rapids, MI 49544-6402
Phone (616) 791-3169

Other names 1

  • Meijer Pharmacy #176 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20121008000019 IL Part B Supplier - Mass Immunization (Roster Biller Only) 4385829480 25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: McHenry, IL; Plainfield, IL; Mokena, IL; Normal, IL; Orland Park, IL; Oswego, IL; Rockford, IL; Rolling Meadows, IL…
O20121009000654 IL DME Supplier - PharmacyDME Supplier - Department StoreDME Supplier - Grocery Store 4385829480 Practice locations: Springfield, IL

Other NPIs on the same Medicare enrollment 25

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 25

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Meijer Pharmacy #1764200 Conestoga Dr, Springfield, IL 62711-7962(217) 547-2410 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Canes and/or Crutches|Walkers Does not accept assignmentParticipating since Jan 1, 2023

National Provider Directory

National Provider Directory
Tax ID family
Meijer37 organizations share this tax ID, including this one

Other organizations with this tax ID 36

Organizations that report the same tax identification number in the National Provider Directory.

View all 36

Locations

4200 Conestoga Dr
Springfield, IL 62711
Phone (217) 321-9323

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1326240000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1395619200000",
    "number": "1013287853",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2929 WALKER AVE NW",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495446402",
            "telephone_number": "616-791-3169",
            "fax_number": "616-735-8532"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4200 CONESTOGA DR",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627117962",
            "telephone_number": "217-547-2410",
            "fax_number": "217-547-2465"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEIJER GREAT LAKES LIMITED PARTNERSHIP",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-11",
        "last_updated": "2014-03-24",
        "status": "A",
        "authorized_official_last_name": "BEAUCH",
        "authorized_official_first_name": "JASON",
        "authorized_official_title_or_position": "DIRECTOR OF PHARMACY MANAGED CARE",
        "authorized_official_telephone_number": "616-791-3169",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "IL",
            "license": "054014283",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": "054014283",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Meijer Pharmacy #176",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Springfield, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.