=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427421650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAI CHAMUNDA KALAMAZOO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2015
-----------------------------------------------------
Last Update Date | 03/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 NORTH PARK STREET
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-381-1888
-----------------------------------------------------
Fax | 269-382-6315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 NORTH PARK STREET
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-381-1888
-----------------------------------------------------
Fax | 269-382-6315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MORGAN GRAHAM TATUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-373-0577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301010761
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------