Provider Demographics
NPI:1184707176
Name:CENTRAL PHARMACY - WILLIAMSTON LLC
Entity type:Organization
Organization Name:CENTRAL PHARMACY - WILLIAMSTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-992-5101
Mailing Address - Street 1:129 S PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-1335
Mailing Address - Country:US
Mailing Address - Phone:517-992-5101
Mailing Address - Fax:517-992-5102
Practice Address - Street 1:129 S PUTNAM ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-1335
Practice Address - Country:US
Practice Address - Phone:517-992-5101
Practice Address - Fax:517-992-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 333600000X
MI53010066933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121634OtherPK
MI4184390Medicaid
MI4948683Medicaid
0252740003Medicare PIN