=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780495549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMER'S COUNTY MARKET INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2025
-----------------------------------------------------
Last Update Date | 01/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 412 N LINCOLN RD
-----------------------------------------------------
City | ESCANABA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49829-1395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-789-0151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 N LINCOLN RD
-----------------------------------------------------
City | ESCANABA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49829-1395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-789-0151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STORE DIRECTOR
-----------------------------------------------------
Name | MR. KURT A STRASLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 906-789-0151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335G00000X
-----------------------------------------------------
Taxonomy Name | Medical Foods Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------