Healthcare Provider Details

I. General information

NPI: 1376655365
Provider Name (Legal Business Name): MATTAWAN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52366 N MAIN ST
MATTAWAN MI
49071-0069
US

IV. Provider business mailing address

PO BOX 69 52366 N MAIN ST
MATTAWAN MI
49071-0069
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-4571
  • Fax: 269-668-3439
Mailing address:
  • Phone: 269-668-4571
  • Fax: 269-668-3439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301005559
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: EDWARD NANTAIS
Title or Position: OWNER PHCST
Credential:
Phone: 269-668-4549