=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356223978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN MEDICAL SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 N MAIN ST
-----------------------------------------------------
City | CHEBOYGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49721-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-627-9949
-----------------------------------------------------
Fax | 231-627-8294
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 345
-----------------------------------------------------
City | CHEBOYGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49721-0345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-627-9949
-----------------------------------------------------
Fax | 231-627-8294
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | TRAVIS WOIDERSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-627-9949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------