=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164856936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL PHARMACY MT HOPE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2013
-----------------------------------------------------
Last Update Date | 07/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 E MOUNT HOPE AVE
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48910-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-316-0711
-----------------------------------------------------
Fax | 517-316-0714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 E MOUNT HOPE AVE
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48910-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-316-0711
-----------------------------------------------------
Fax | 517-316-0714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER/PIC
-----------------------------------------------------
Name | MICHAEL SALQUIST
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 517-404-5178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301010169
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------