MEDICARE: FAMILY FARE, 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
2	333600000X	Pharmacy	5301008100	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2312952	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1952401283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY FARE, LLC

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

Provider Business Practice Location Address
First Line	:	430 N LAKE ST
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-1104
Country	:	US
Telephone Number	:	231-582-2101
Fax Number	:	231-582-1749

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	12/07/2023

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Directions to “FAMILY FARE, LLC ” Practice Location

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