=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033320528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVO'S FAMILY MARKETS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 10/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 847 S KALAMAZOO ST
-----------------------------------------------------
City | PAW PAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49079-9230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-657-1778
-----------------------------------------------------
Fax | 269-657-1779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1527 MOMENTUM PL SPARTAN PHARMACY NORTH
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60689-5315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-878-8584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | AMY ELLIS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 616-878-2848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301008631
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------