Provider Demographics
NPI:1235323999
Name:WASHTENAW MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:WASHTENAW MEDICAL PHARMACY LLC
Other - Org Name:CENTRAL PHARMACY - PATIENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSEIBEH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-574-3434
Mailing Address - Street 1:3955 PATIENT CARE DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4299
Mailing Address - Country:US
Mailing Address - Phone:517-393-1000
Mailing Address - Fax:517-393-1018
Practice Address - Street 1:3955 PATIENT CARE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4299
Practice Address - Country:US
Practice Address - Phone:517-393-1000
Practice Address - Fax:517-393-1018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043623OtherPK
MI2370790Medicaid