Provider Demographics
NPI:1699854497
Name:MSM HOLDCO, LLC
Entity Type:Organization
Organization Name:MSM HOLDCO, LLC
Other - Org Name:MARTIN'S 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 1:3800 E MISHAWAKA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-3540
Practice Address - Country:US
Practice Address - Phone:574-875-9423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200376290AMedicaid