Provider Demographics
NPI:1164856936
Name:CENTRAL PHARMACY MT HOPE LLC
Entity Type:Organization
Organization Name:CENTRAL PHARMACY MT HOPE LLC
Other - Org Name:CENTRAL PHARMACY - MT. HOPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-404-5178
Mailing Address - Street 1:1001 E MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-1822
Mailing Address - Country:US
Mailing Address - Phone:517-316-0711
Mailing Address - Fax:517-316-0714
Practice Address - Street 1:1001 E MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1822
Practice Address - Country:US
Practice Address - Phone:517-316-0711
Practice Address - Fax:517-316-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010101693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141865OtherPK
MI2378291Medicaid