Provider Demographics
NPI:1326057308
Name:FOWLERVILLE RX LLC
Entity Type:Organization
Organization Name:FOWLERVILLE RX LLC
Other - Org Name:FOWLERVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDAGATLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-316-6716
Mailing Address - Street 1:119 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836
Mailing Address - Country:US
Mailing Address - Phone:517-223-9832
Mailing Address - Fax:517-223-7267
Practice Address - Street 1:119 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836
Practice Address - Country:US
Practice Address - Phone:517-223-9832
Practice Address - Fax:517-223-7267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010042323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2339100Medicaid