Provider Demographics
NPI:1053856419
Name:CENTRAL PHARMACY - CHARLOTTE LLC
Entity Type:Organization
Organization Name:CENTRAL PHARMACY - CHARLOTTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSEIBEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-543-9990
Mailing Address - Street 1:354 S COCHRAN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1569
Mailing Address - Country:US
Mailing Address - Phone:517-543-9990
Mailing Address - Fax:517-543-9910
Practice Address - Street 1:354 S COCHRAN AVE STE 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1569
Practice Address - Country:US
Practice Address - Phone:517-543-9990
Practice Address - Fax:517-543-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010111083336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168119OtherPK
MI2383115Medicaid