Healthcare Provider Details

I. General information

NPI: 1548694102
Provider Name (Legal Business Name): MURKS VILLAGE MARKET INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S STATE ST # M-40
GOBLES MI
49055-9724
US

IV. Provider business mailing address

407 S STATE ST # M-40
GOBLES MI
49055-9724
US

V. Phone/Fax

Practice location:
  • Phone: 269-628-0035
  • Fax: 269-628-0037
Mailing address:
  • Phone: 269-628-0035
  • Fax: 269-628-0037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010157
License Number StateMI

VIII. Authorized Official

Name: DAVID LONGTIN
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 269-637-8655