Provider Demographics
NPI:1275673428
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:OWNER PHARMACIST
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:R PH
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:2007-02-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010010393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2318283OtherBLUE CROSS BLUE SHIELD MI
MI2318283Medicaid
MI2318283OtherBLUE CROSS BLUE SHIELD MI