Provider Demographics
NPI:1689481236
Name:GREAT LAKES R.PH. CORP
Entity type:Organization
Organization Name:GREAT LAKES R.PH. CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-998-6772
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-0053
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:49344-9772
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:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy