Provider Demographics
NPI:1275648818
Name:CENTRAL PHARMACY - MAPLE VALLEY LLC
Entity Type:Organization
Organization Name:CENTRAL PHARMACY - MAPLE VALLEY LLC
Other - Org Name:MAPLE VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-615-4700
Mailing Address - Street 1:219 N MAIN ST
Mailing Address - Street 2:P. O. BOX 930
Mailing Address - City:NASHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49073-9577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:MI
Practice Address - Zip Code:49073-9577
Practice Address - Country:US
Practice Address - Phone:517-615-4700
Practice Address - Fax:517-615-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010082613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0864630001Medicare NSC