MEDICARE: CENTRAL PHARMACY-MATTAWAN 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	3336C0003X	Community/Retail Pharmacy	5301009144	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
2	2121009	OTHER		PK

General Provider Information

NPI Number	:	1356571988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL PHARMACY-MATTAWAN LLC

Provider Business Mailing Address
First Line	:	56109 VILLAGE CENTER CIR
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-8368
Country	:	US
Telephone Number	:	269-668-6801
Fax Number	:	269-668-6802

Provider Business Practice Location Address
First Line	:	56109 VILLAGE CENTER CIR
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-8368
Country	:	US
Telephone Number	:	269-668-6801
Fax Number	:	269-668-6802

Authorized Official
Title or Position	:	OWNER
Name	:	MOHAMED A BEYDOUN
Credential	:
Telephone Number	:	269-673-4700

Provider Enumeration Date	:	07/16/2009
Last Update Date	:	03/28/2023

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