Healthcare Provider Details

I. General information

NPI: 1730327784
Provider Name (Legal Business Name): AFAV ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52366 N MAIN ST
MATTAWAN MI
49071-9332
US

IV. Provider business mailing address

PO BOX 203
MATTAWAN MI
49071-0203
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-3366
  • Fax: 269-668-3439
Mailing address:
  • Phone: 269-668-4549
  • Fax: 269-668-3439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009053
License Number StateMI

VIII. Authorized Official

Name: ANDREA FAVREAU
Title or Position: OWNER
Credential:
Phone: 269-998-8320