Provider Demographics
NPI:1346378007
Name:M & I ENTERPRISES, INC.
Entity Type:Organization
Organization Name:M & I ENTERPRISES, INC.
Other - Org Name:ST. LUKE PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAT
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:626-791-7595
Mailing Address - Street 1:2554 E WASHINGTON BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1445
Mailing Address - Country:US
Mailing Address - Phone:626-791-7595
Mailing Address - Fax:626-791-3564
Practice Address - Street 1:2554 E WASHINGTON BLVD
Practice Address - Street 2:STE B
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1445
Practice Address - Country:US
Practice Address - Phone:626-791-7595
Practice Address - Fax:626-791-3564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY545843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005197OtherPK
0581872OtherOTHER ID NUMBER
CA5553870001Medicare NSC