Provider Demographics
NPI:1356571988
Name:CENTRAL PHARMACY-MATTAWAN LLC
Entity type:Organization
Organization Name:CENTRAL PHARMACY-MATTAWAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEYDOUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-673-4700
Mailing Address - Street 1:56109 VILLAGE CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-8368
Mailing Address - Country:US
Mailing Address - Phone:269-668-6801
Mailing Address - Fax:269-668-6802
Practice Address - Street 1:56109 VILLAGE CENTER CIR
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-8368
Practice Address - Country:US
Practice Address - Phone:269-668-6801
Practice Address - Fax:269-668-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010091443336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2372972Medicaid
2121009OtherPK