Provider Demographics
NPI:1558692517
Name:CENTRAL PHARMACY - POTTERVILLE LLC
Entity Type:Organization
Organization Name:CENTRAL PHARMACY - POTTERVILLE LLC
Other - Org Name:POTTERVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:HOSSAM
Authorized Official - Last Name:SAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-645-9800
Mailing Address - Street 1:121 E LANSING RD
Mailing Address - Street 2:
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876-9799
Mailing Address - Country:US
Mailing Address - Phone:517-645-9800
Mailing Address - Fax:517-645-0900
Practice Address - Street 1:121 E LANSING RD
Practice Address - Street 2:
Practice Address - City:POTTERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48876-9799
Practice Address - Country:US
Practice Address - Phone:517-645-9800
Practice Address - Fax:517-645-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558692517Medicaid
2373532OtherNCPDP PROVIDER IDENTIFICATION NUMBER