Provider Demographics
NPI:1114345907
Name:DIVINICARE LLC
Entity Type:Organization
Organization Name:DIVINICARE LLC
Other - Org Name:DIVINICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAWCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-745-4697
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:SUITE A
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-0310
Mailing Address - Country:US
Mailing Address - Phone:231-745-4697
Mailing Address - Fax:231-745-8640
Practice Address - Street 1:868 MICHIGAN AVE STE A
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7123
Practice Address - Country:US
Practice Address - Phone:231-745-4697
Practice Address - Fax:231-745-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010103793336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146577OtherPK
MI1114345907Medicaid