MEDICARE: PREVO'S FAMILY MARKETS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	5301008371	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2042552	OTHER		PK

General Provider Information

NPI Number	:	1003973561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVO'S FAMILY MARKETS LLC

Provider Business Mailing Address
First Line	:	SPARTAN PHARMACY NORTH
Second Line	:	1527 MOMENTUM PLACE
City	:	CHICAGO
State	:	IL
Zip	:	60689-5315
Country	:	US
Telephone Number	:	616-878-8584
Fax Number	:	616-878-8850

Provider Business Practice Location Address
First Line	:	9375 CHERRY VALLEY AVE SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-9506
Country	:	US
Telephone Number	:	616-891-7898
Fax Number	:	616-891-8097

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	AMY ELLIS
Credential	:	RPH
Telephone Number	:	616-878-2848

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	01/22/2026

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