Provider Demographics
NPI:1760616189
Name:CENTERLINE PHARMACY LLC
Entity Type:Organization
Organization Name:CENTERLINE PHARMACY LLC
Other - Org Name:CENTERLINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCHHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-427-5344
Mailing Address - Street 1:8033 E 10 MILE RD
Mailing Address - Street 2:STE 103
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8033 E 10 MILE RD
Practice Address - Street 2:STE 103
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1427
Practice Address - Country:US
Practice Address - Phone:586-427-5344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010091133336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2372807OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI6450150001Medicare NSC