Provider Demographics
NPI:1205845898
Name:MFMM INC
Entity Type:Organization
Organization Name:MFMM INC
Other - Org Name:SOUTH SUBURBAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-798-4300
Mailing Address - Street 1:3330 W 177TH ST
Mailing Address - Street 2:STE 1E
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2184
Mailing Address - Country:US
Mailing Address - Phone:708-798-4300
Mailing Address - Fax:708-798-4447
Practice Address - Street 1:3330 W 177TH ST
Practice Address - Street 2:STE 1E
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2184
Practice Address - Country:US
Practice Address - Phone:708-798-4300
Practice Address - Fax:708-798-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336I0012X, 3336M0003X
IL054.0158263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023181OtherPK
IL=========001Medicaid