Provider Demographics
NPI:1588917447
Name:MPKM, LLC
Entity type:Organization
Organization Name:MPKM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:HOGAN
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-203-4797
Mailing Address - Street 1:608 SARI DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-4227
Mailing Address - Country:US
Mailing Address - Phone:702-203-4797
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST STE 118
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2462
Practice Address - Country:US
Practice Address - Phone:702-203-4797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000689-C3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy