MEDICARE: AFAV ENTERPRISES 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	5301009053	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2372465	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1730327784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFAV ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	PO BOX 203
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-0203
Country	:	US
Telephone Number	:	269-668-4549
Fax Number	:	269-668-3439

Provider Business Practice Location Address
First Line	:	52366 N MAIN ST
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-9332
Country	:	US
Telephone Number	:	269-668-3366
Fax Number	:	269-668-3439

Authorized Official
Title or Position	:	OWNER
Name	:	ANDREA FAVREAU
Credential	:
Telephone Number	:	269-998-8320

Provider Enumeration Date	:	01/29/2009
Last Update Date	:	06/19/2009

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Directions to “AFAV ENTERPRISES LLC ” Practice Location

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