Provider Demographics
NPI:1588663132
Name:CENTRAL PHARMACY - LIVONIA LLC
Entity Type:Organization
Organization Name:CENTRAL PHARMACY - LIVONIA LLC
Other - Org Name:MERRIMAN DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VENISETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-427-3430
Mailing Address - Street 1:31320 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3644
Mailing Address - Country:US
Mailing Address - Phone:734-427-3430
Mailing Address - Fax:734-427-1293
Practice Address - Street 1:31320 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3644
Practice Address - Country:US
Practice Address - Phone:734-427-3430
Practice Address - Fax:734-427-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-16
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010110053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164086OtherPK
2043117OtherPK
5426660001Medicare NSC