Active NPI
MSM Holdco, LLC
Doing business as Martin's Pharmacy #2389
- Community/Retail Pharmacy
- Mishawaka, IN
National Provider Identifier
1629525738
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- 60006269A
- Legal business name
- MSM HOLDCO, LLC
- Doing business as
- Martin's Pharmacy #2389
Martin's Pharmacy at SJRMC - Practice address
- 611 E Douglas Rd Ste 104
Mishawaka, IN 46545-1480 - Phone
- (574) 247-1000
- Fax
- (574) 208-6020
- NPI assigned
- Sep 7, 2016
- Last updated
- Dec 7, 2023
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Amy Ellis, RPH
- Title
- Director of Pharmacy
- Phone
- (616) 878-2848
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 60006269A | IN | Primary |
Addresses
Primary practice location
611 E Douglas Rd Ste 104
Mishawaka, IN 46545-1480
Mailing address
1527 Momentum Place
Chicago, IL 60689-5315
Phone (616) 878-8584
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2163717 | Other | PK |
Other names 3
- Martin's Pharmacy #2389
- Martin's Pharmacy at SJRMC
- Martin's Super Markets Inc
National Provider Directory
National Provider Directory- Tax ID family
- Martin's Pharmacy 11
Other organizations with this tax ID 10
Organizations that report the same tax identification number in the National Provider Directory.
Locations
611 E Douglas Rd
Ste 104
Mishawaka, IN 46545
Phone (574) 247-1000
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1473206400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1701907200000",
"number": "1629525738",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1527 MOMENTUM PLACE",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606895315",
"telephone_number": "616-878-8584",
"fax_number": "574-208-6020"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "611 E DOUGLAS RD STE 104",
"city": "MISHAWAKA",
"state": "IN",
"postal_code": "465451480",
"telephone_number": "574-247-1000",
"fax_number": "574-208-6020"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MSM HOLDCO, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2016-09-07",
"last_updated": "2023-12-07",
"certification_date": "2023-12-07",
"status": "A",
"authorized_official_last_name": "ELLIS",
"authorized_official_first_name": "AMY",
"authorized_official_title_or_position": "DIRECTOR OF PHARMACY",
"authorized_official_telephone_number": "616-878-2848",
"authorized_official_credential": "RPH"
},
"taxonomies": [
{
"code": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": "IN",
"license": "60006269A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2163717",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Martin's Pharmacy #2389",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Martin's Pharmacy at SJRMC",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Martin's Pharmacy at SJRMC",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Martin's Super Markets Inc",
"code": "4",
"type": "Former Legal Business Name"
}
]
}Other providers in Mishawaka, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.