1396845624 NPI number — FAMILY FARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396845624 NPI number — FAMILY FARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY FARE PHARMACY 408
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396845624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1527 MOMENTUM PL
Provider Second Line Business Mailing Address:
SPARTAN PHARMACY NORTH
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60689-5315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-878-8584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
565 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49345-1568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-887-8861
Provider Business Practice Location Address Fax Number:
616-887-9050
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
616-878-2848

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  5301007083 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2348527 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4147477 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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