Provider Demographics
NPI:1093291692
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DABAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-553-5000
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074-0022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5585 GULL RD STE 120
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-6704
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:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy