=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508610601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL PHARMACY- EATON RAPIDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2024
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 S MAIN ST
-----------------------------------------------------
City | EATON RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48827-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-663-6811
-----------------------------------------------------
Fax | 517-663-1732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 S MAIN ST
-----------------------------------------------------
City | EATON RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48827-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-663-6811
-----------------------------------------------------
Fax | 517-663-1732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | HASSAN MOHAMAD KRAIDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-465-9656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------