Healthcare Provider Details

I. General information

NPI: 1356571988
Provider Name (Legal Business Name): CENTRAL PHARMACY-MATTAWAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56109 VILLAGE CENTER CIR
MATTAWAN MI
49071-8368
US

IV. Provider business mailing address

56109 VILLAGE CENTER CIR
MATTAWAN MI
49071-8368
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-6801
  • Fax: 269-668-6802
Mailing address:
  • Phone: 269-668-6801
  • Fax: 269-668-6802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009144
License Number StateMI

VIII. Authorized Official

Name: MOHAMED A BEYDOUN
Title or Position: OWNER
Credential:
Phone: 269-673-4700