Provider Demographics
NPI:1124137740
Name:STATE STREET PHARMACY & WELLNESS CENTER INC
Entity type:Organization
Organization Name:STATE STREET PHARMACY & WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOVISHLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-672-3500
Mailing Address - Street 1:192 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-1550
Mailing Address - Country:US
Mailing Address - Phone:989-672-3500
Mailing Address - Fax:989-672-3555
Practice Address - Street 1:192 N STATE ST
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-1550
Practice Address - Country:US
Practice Address - Phone:989-672-3500
Practice Address - Fax:989-672-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010070283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2360131OtherNCPDP NUMBER
MI2360131OtherNCPDP NUMBER