MEDICARE: MARTIN'S SUPER MARKETS OF STEVENSVILLE 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	3336C0003X	Community/Retail Pharmacy	5301007780	MI

General Provider Information

NPI Number	:	1245319060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTIN'S SUPER MARKETS OF STEVENSVILLE LLC

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

Provider Business Practice Location Address
First Line	:	5637 CLEVELAND AVE
Second Line	:
City	:	STEVENSVILLE
State	:	MI
Zip	:	49127-9613
Country	:	US
Telephone Number	:	269-429-8441
Fax Number	:

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	12/07/2023

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