MEDICARE: CENTRAL LAKE PHARMACY INC

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	5301005744	MI
2	3336C0003X	Community/Retail Pharmacy	5301005744	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235272568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL LAKE PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 425
Second Line	:
City	:	CENTRAL LAKE
State	:	MI
Zip	:	49622-0425
Country	:	US
Telephone Number	:	231-544-2929
Fax Number	:	231-544-5408

Provider Business Practice Location Address
First Line	:	2424 N MAIN STREET
Second Line	:
City	:	CENTRAL LAKE
State	:	MI
Zip	:	49622-0425
Country	:	US
Telephone Number	:	231-544-2929
Fax Number	:	231-544-5408

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DUANE LYLE CHAPPUIES
Credential	:	RPH
Telephone Number	:	231-536-7657

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	02/12/2016

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