MEDICARE: CET PHARMACY LTC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy	5301010531	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2146993	OTHER		PK

General Provider Information

NPI Number	:	1447668843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CET PHARMACY LTC LLC

Provider Business Mailing Address
First Line	:	6140 28TH ST SE STE 105
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6938
Country	:	US
Telephone Number	:	616-965-7480
Fax Number	:	616-974-8205

Provider Business Practice Location Address
First Line	:	6140 28TH ST SE STE 105
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6938
Country	:	US
Telephone Number	:	616-965-7480
Fax Number	:	616-974-8205

Authorized Official
Title or Position	:	OFFICER
Name	:	EDDY AOUN
Credential	:
Telephone Number	:	313-525-2911

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	12/14/2015

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