Provider Demographics
NPI:1518468776
Name:CENTRAL PHARMACY-OWOSSO
Entity Type:Organization
Organization Name:CENTRAL PHARMACY-OWOSSO
Other - Org Name:CENTRAL PHARMACY-OWOSSO LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSEIBEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-574-3434
Mailing Address - Street 1:111 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2819
Mailing Address - Country:US
Mailing Address - Phone:989-725-1344
Mailing Address - Fax:989-729-0109
Practice Address - Street 1:111 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2819
Practice Address - Country:US
Practice Address - Phone:989-725-1344
Practice Address - Fax:989-729-0109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010105673336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1851337760Medicaid
2175989OtherPK