Provider Demographics
NPI:1366693665
Name:MSM HOLDCO, LLC
Entity Type:Organization
Organization Name:MSM HOLDCO, LLC
Other - Org Name:MARTINS SUPER MARKETS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-878-2848
Mailing Address - Street 1:1527 MOMENTUM PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5315
Mailing Address - Country:US
Mailing Address - Phone:616-878-8584
Mailing Address - Fax:
Practice Address - Street 1:314 N IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1543
Practice Address - Country:US
Practice Address - Phone:574-254-2323
Practice Address - Fax:574-254-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006166A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1562330OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4607020008Medicare NSC