MEDICARE: M K STORES INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	5301003442	MI
2	3336C0003X	Community/Retail Pharmacy	5301003442	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2328246	OTHER	MI	NABP NUMBER

General Provider Information

NPI Number	:	1548275951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M K STORES INC

Provider Business Mailing Address
First Line	:	933 RIVERSIDE PLZ
Second Line	:
City	:	IRON RIVER
State	:	MI
Zip	:	49935-1529
Country	:	US
Telephone Number	:	906-265-5149
Fax Number	:	906-265-4970

Provider Business Practice Location Address
First Line	:	933 RIVERSIDE PLZ
Second Line	:
City	:	IRON RIVER
State	:	MI
Zip	:	49935-1529
Country	:	US
Telephone Number	:	906-265-5149
Fax Number	:	906-265-4970

Authorized Official
Title or Position	:	HEAD OF PHARMACY
Name	:	MICHAEL C RUSSELL
Credential	:
Telephone Number	:	906-485-5592

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	04/10/2024

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Directions to “M K STORES INC ” Practice Location

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