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General NPI Number Information
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NPI Number | 1245319060
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Entity Type | Organization
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Legal Business Name | MARTIN'S SUPER MARKETS OF STEVENSVILLE LLC
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Dates
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Enumeration Date | 11/03/2006
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Last Update Date | 12/07/2023
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Provider Practice Location Address
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Address Line | 5637 CLEVELAND AVE
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City | STEVENSVILLE
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State | MI
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Zip | 49127-9613
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Country | US
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Telephone | 269-429-8441
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Fax |
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Provider Business Mailing Address
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Address Line | 1527 MOMENTUM PLACE
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City | CHICAGO
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State | IL
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Zip | 60689-5315
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Country | US
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Telephone | 616-878-8584
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF PHARMACY
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Name | AMY ELLIS
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Credential | RPH
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Telephone | 616-878-2848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301007780
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License Number State | MI
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