Provider Demographics
NPI:1114195062
Name:MMJ COCOS BOUTIQUE INC
Entity Type:Organization
Organization Name:MMJ COCOS BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISOL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-836-0011
Mailing Address - Street 1:921 RIDGE RD # 2
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1739
Mailing Address - Country:US
Mailing Address - Phone:219-836-0011
Mailing Address - Fax:219-836-0011
Practice Address - Street 1:921 RIDGE RD # 2
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1739
Practice Address - Country:US
Practice Address - Phone:219-836-0011
Practice Address - Fax:219-836-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6070750001Medicare NSC