Provider Demographics
NPI:1982792214
Name:PUTVIN HEALTH MART OF MUNISING INC
Entity Type:Organization
Organization Name:PUTVIN HEALTH MART OF MUNISING INC
Other - Org Name:PUTVIN DRUG STORE A RADIO SHACK DEALER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DEFRANCESCO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-387-2248
Mailing Address - Street 1:119 ELM AVE
Mailing Address - Street 2:PO BOX 220
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-1105
Mailing Address - Country:US
Mailing Address - Phone:906-387-2248
Mailing Address - Fax:906-387-3852
Practice Address - Street 1:119 ELM AVE
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1105
Practice Address - Country:US
Practice Address - Phone:906-387-2248
Practice Address - Fax:906-387-3852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010004153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2514746Medicaid
MI2514746Medicaid