Healthcare Provider Details

I. General information

NPI: 1497704456
Provider Name (Legal Business Name): MK STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 W GENESEE ST
IRON RIVER MI
49935-1437
US

IV. Provider business mailing address

1330 US 41 W
ISHPEMING MI
49849-3152
US

V. Phone/Fax

Practice location:
  • Phone: 906-265-2312
  • Fax: 906-265-5608
Mailing address:
  • Phone: 906-485-5592
  • Fax: 906-485-4482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010216
License Number StateMI

VIII. Authorized Official

Name: MICHAEL C RUSSELL
Title or Position: HEAD OF PHARMACY
Credential:
Phone: 906-485-5592