=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497704456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MK STORES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 04/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 W GENESEE ST
-----------------------------------------------------
City | IRON RIVER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49935-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-265-2312
-----------------------------------------------------
Fax | 906-265-5608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1330 US 41 W
-----------------------------------------------------
City | ISHPEMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49849-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-485-5592
-----------------------------------------------------
Fax | 906-485-4482
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEAD OF PHARMACY
-----------------------------------------------------
Name | MICHAEL C RUSSELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 906-485-5592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301010216
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------