Healthcare Provider Details

I. General information

NPI: 1184902090
Provider Name (Legal Business Name): FAMILY FARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 N STATE ST
GLADWIN MI
48624-1246
US

IV. Provider business mailing address

1527 MOMENTUM PL SPARTAN PHARMACY NORTH
CHICAGO IL
60689-5315
US

V. Phone/Fax

Practice location:
  • Phone: 989-426-9215
  • Fax: 989-426-2433
Mailing address:
  • Phone: 616-878-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateMI

VIII. Authorized Official

Name: AMY SCOTT ELLIS
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 616-878-2848