Provider Demographics
NPI:1073950994
Name:CET PHARMACY GRAND RAPIDS LLC
Entity Type:Organization
Organization Name:CET PHARMACY GRAND RAPIDS LLC
Other - Org Name:CET PHARMACY 1005
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHADI
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-818-0766
Mailing Address - Street 1:504 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5600
Mailing Address - Country:US
Mailing Address - Phone:616-957-9191
Mailing Address - Fax:616-957-9160
Practice Address - Street 1:2060 E PARIS AVE SE STE 110
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-957-9191
Practice Address - Fax:616-957-9160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-01
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010101123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073950994Medicaid
2140605OtherPK