Provider Demographics
NPI:1033125836
Name:M K STORES INC
Entity Type:Organization
Organization Name:M K STORES INC
Other - Org Name:SNYDER DRUG #104
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEAD OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-485-5592
Mailing Address - Street 1:130 E STATE HIGHWAY M-35
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841
Mailing Address - Country:US
Mailing Address - Phone:906-346-0104
Mailing Address - Fax:906-346-6422
Practice Address - Street 1:130 E STATE HIGHWAY M-35
Practice Address - Street 2:
Practice Address - City:GWINN
Practice Address - State:MI
Practice Address - Zip Code:49841
Practice Address - Country:US
Practice Address - Phone:906-346-0104
Practice Address - Fax:906-346-6422
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MK STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-01
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006378332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2355433OtherNABP NUMBER
MI2355433OtherNABP NUMBER