=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447514385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M.K. STORES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2012
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7344 STATE HWY M-123
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-293-9900
-----------------------------------------------------
Fax | 906-293-9909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7344 STATE HWY M-123
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-293-9900
-----------------------------------------------------
Fax | 906-293-9909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | MR. MICHAEL CHARLES RUSSELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 906-250-7034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301009845
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------