Provider Demographics
NPI:1003973561
Name:PREVOS FAMILY MARKETS INC
Entity Type:Organization
Organization Name:PREVOS FAMILY MARKETS INC
Other - Org Name:D & W PHARMACY 1577
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-878-2848
Mailing Address - Street 1:SPARTAN PHARMACY NORTH
Mailing Address - Street 2:1527 MOMENTUM PLACE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5315
Mailing Address - Country:US
Mailing Address - Phone:616-878-8584
Mailing Address - Fax:616-878-8850
Practice Address - Street 1:9375 CHERRY VALLEY AVE SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9506
Practice Address - Country:US
Practice Address - Phone:616-891-7898
Practice Address - Fax:616-891-8097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010083713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042552OtherPK