Provider Demographics
NPI:1609114719
Name:CEREAL CITY MEDICAL INC
Entity Type:Organization
Organization Name:CEREAL CITY MEDICAL INC
Other - Org Name:CEREAL CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUBRAMANIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-948-2080
Mailing Address - Street 1:3600 CAPITAL AVE SW
Mailing Address - Street 2:STE 202
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-9393
Mailing Address - Country:US
Mailing Address - Phone:269-979-1221
Mailing Address - Fax:269-979-2511
Practice Address - Street 1:3600 CAPITAL AVE SW
Practice Address - Street 2:STE 202
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-9393
Practice Address - Country:US
Practice Address - Phone:269-979-1221
Practice Address - Fax:269-979-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301009930333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149649OtherPK