Healthcare Provider Details

I. General information

NPI: 1982792214
Provider Name (Legal Business Name): PUTVIN HEALTH MART OF MUNISING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 ELM AVE
MUNISING MI
49862-1105
US

IV. Provider business mailing address

119 ELM AVE PO BOX 220
MUNISING MI
49862-1105
US

V. Phone/Fax

Practice location:
  • Phone: 906-387-2248
  • Fax: 906-387-3852
Mailing address:
  • Phone: 906-387-2248
  • Fax: 906-387-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301000415
License Number StateMI

VIII. Authorized Official

Name: MR. JEFFREY ALAN DEFRANCESCO
Title or Position: OWNER
Credential: RPH
Phone: 906-387-2248