Provider Demographics
NPI:1013924323
Name:MK STORES INC
Entity Type:Organization
Organization Name:MK STORES INC
Other - Org Name:MK STORES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-485-5592
Mailing Address - Street 1:380 US HIGHWAY 41 EAST
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866
Mailing Address - Country:US
Mailing Address - Phone:906-475-4424
Mailing Address - Fax:906-475-4616
Practice Address - Street 1:380 US HIGHWAY 41 EAST
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866
Practice Address - Country:US
Practice Address - Phone:906-475-4424
Practice Address - Fax:906-475-4616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010066353336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2357386OtherNABP NUMBER
MI1030330008Medicare NSC