Healthcare Provider Details

I. General information

NPI: 1649277369
Provider Name (Legal Business Name): MAR-MAIN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 N MICHIGAN ST
SOUTH BEND IN
46601-1228
US

IV. Provider business mailing address

426 N MICHIGAN ST
SOUTH BEND IN
46601-1228
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-3184
  • Fax:
Mailing address:
  • Phone: 574-234-3184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number60005199A
License Number StateIN

VIII. Authorized Official

Name: DR. JAN M BOPP
Title or Position: PHARMACIST
Credential: PHARMD, RPH
Phone: 574-234-3184