Provider Demographics
NPI:1750963088
Name:MACKENTHUN SUPERMARKETS, INC.
Entity type:Organization
Organization Name:MACKENTHUN SUPERMARKETS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:AKHAPHONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-442-2512
Mailing Address - Street 1:851 MARKETPLACE DR
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1548
Mailing Address - Country:US
Mailing Address - Phone:952-442-2512
Mailing Address - Fax:952-442-5787
Practice Address - Street 1:851 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1548
Practice Address - Country:US
Practice Address - Phone:952-442-2512
Practice Address - Fax:952-442-5787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KM SUPERMARKETS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty