Provider Demographics
NPI:1598002479
Name:MEDPLEX PHARMACY LLC
Entity Type:Organization
Organization Name:MEDPLEX PHARMACY LLC
Other - Org Name:MEDPLEX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER, AO. PIC
Authorized Official - Prefix:
Authorized Official - First Name:RAGHAVENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-980-2646
Mailing Address - Street 1:6318 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48722-9566
Mailing Address - Country:US
Mailing Address - Phone:989-746-9500
Mailing Address - Fax:989-746-9501
Practice Address - Street 1:6318 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9566
Practice Address - Country:US
Practice Address - Phone:989-746-9500
Practice Address - Fax:989-746-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010105413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147838OtherPK
MI20141022129717Medicaid