Provider Demographics
NPI:1265865372
Name:MADHAV PHARMACY LLC
Entity Type:Organization
Organization Name:MADHAV PHARMACY LLC
Other - Org Name:LAKEWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAVI S VARMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NADIMPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-359-2326
Mailing Address - Street 1:24800 HARPER AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1292
Mailing Address - Country:US
Mailing Address - Phone:586-359-2326
Mailing Address - Fax:586-200-2051
Practice Address - Street 1:24800 HARPER AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1292
Practice Address - Country:US
Practice Address - Phone:586-359-2326
Practice Address - Fax:586-200-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010101503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy