Provider Demographics
NPI:1740555739
Name:CARNIVAL PHARMACY LLC
Entity type:Organization
Organization Name:CARNIVAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASULU
Authorized Official - Middle Name:
Authorized Official - Last Name:PATHURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-475-2200
Mailing Address - Street 1:1101 E WALTON BLVD
Mailing Address - Street 2:#202
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1591
Mailing Address - Country:US
Mailing Address - Phone:248-475-2200
Mailing Address - Fax:
Practice Address - Street 1:1101 E WALTON BLVD
Practice Address - Street 2:#202
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1591
Practice Address - Country:US
Practice Address - Phone:248-475-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
MI53010097643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2376451OtherNCPDP PROVIDER IDENTIFICATION NUMBER