Provider Demographics
NPI:1376655365
Name:MATTAWAN PHARMACY
Entity Type:Organization
Organization Name:MATTAWAN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NANTAIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-668-4549
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:52366 N MAIN ST
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-0069
Mailing Address - Country:US
Mailing Address - Phone:269-668-4571
Mailing Address - Fax:269-668-3439
Practice Address - Street 1:52366 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-0069
Practice Address - Country:US
Practice Address - Phone:269-668-4571
Practice Address - Fax:269-668-3439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301005559333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2348565Medicaid
2348565OtherOTHER ID NUMBER-COMMERCIAL NUMBER