Provider Demographics
NPI:1114035821
Name:MANISTIQUE PHARMACEUTICALS INC.
Entity Type:Organization
Organization Name:MANISTIQUE PHARMACEUTICALS INC.
Other - Org Name:PUTVIN DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROHDE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-341-5494
Mailing Address - Street 1:211 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1425
Mailing Address - Country:US
Mailing Address - Phone:906-341-5494
Mailing Address - Fax:906-341-6752
Practice Address - Street 1:211 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1425
Practice Address - Country:US
Practice Address - Phone:906-341-5494
Practice Address - Fax:906-341-6752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301001039332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540G70250OtherBLUE CROSS BLUE SHIELD
MI2542606Medicaid
MI0207150001Medicare NSC
MI0207150001Medicare ID - Type UnspecifiedDME, P&O