Provider Demographics
NPI:1750440855
Name:PREVOS FAMILY MARKETS, INC
Entity type:Organization
Organization Name:PREVOS FAMILY MARKETS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 PL
Mailing Address - Street 2:SPARTAN PHARMACY NORTH
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5315
Mailing Address - Country:US
Mailing Address - Phone:616-878-9594
Mailing Address - Fax:
Practice Address - Street 1:201 MARCELL DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1364
Practice Address - Country:US
Practice Address - Phone:616-863-9376
Practice Address - Fax:616-863-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010082313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2368985OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2368985OtherOTHER ID NUMBER-COMMERCIAL NUMBER