Provider Demographics
NPI:1386650182
Name:M K STORES INC
Entity Type:Organization
Organization Name:M K STORES INC
Other - Org Name:SNYDER DRUG #207
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEMS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-361-0486
Mailing Address - Street 1:415 E M-28
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862
Mailing Address - Country:US
Mailing Address - Phone:906-387-4855
Mailing Address - Fax:906-387-5736
Practice Address - Street 1:415 E M-28
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862
Practice Address - Country:US
Practice Address - Phone:906-387-4855
Practice Address - Fax:906-387-5736
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MK STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-01
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006949332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2359594OtherNABP NUMBER
MI1030330011Medicare NSC