MEDICARE: MARTIN'S SUPER MARKETS OF ST. JOSEPH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	5301007540	MI

General Provider Information

NPI Number	:	1396824116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTIN'S SUPER MARKETS OF ST. JOSEPH, LLC

Provider Business Mailing Address
First Line	:	1527 MOMENTUM PLACE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60689-5315
Country	:	US
Telephone Number	:	616-878-8584
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 S CLEVELAND AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2601
Country	:	US
Telephone Number	:	269-983-5847
Fax Number	:	269-983-5869

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	AMY ELLIS
Credential	:	RPH
Telephone Number	:	616-878-2848

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	12/07/2023

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