Provider Demographics
NPI:1013012236
Name:MEDICINE MART INC.
Entity Type:Organization
Organization Name:MEDICINE MART INC.
Other - Org Name:GULL POINTE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DABAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-553-5000
Mailing Address - Street 1:5585 GULL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-6703
Mailing Address - Country:US
Mailing Address - Phone:269-553-5000
Mailing Address - Fax:269-553-0555
Practice Address - Street 1:5585 GULL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-6703
Practice Address - Country:US
Practice Address - Phone:269-553-5000
Practice Address - Fax:269-553-0555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010075053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4369377Medicaid
4453270001Medicare ID - Type Unspecified