Provider Demographics
NPI:1861802456
Name:MEIJER
Entity type:Organization
Organization Name:MEIJER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIDOUN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-974-1821
Mailing Address - Street 1:2825 GABRIELLA ST
Mailing Address - Street 2:APT 403
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 E BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2250
Practice Address - Country:US
Practice Address - Phone:630-783-5365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295682305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service