1447668843 NPI number — CET PHARMACY LTC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447668843 NPI number — CET PHARMACY LTC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CET PHARMACY LTC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447668843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6140 28TH ST SE STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546-6938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-965-7480
Provider Business Mailing Address Fax Number:
616-974-8205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6140 28TH ST SE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-6938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-965-7480
Provider Business Practice Location Address Fax Number:
616-974-8205
Provider Enumeration Date:
07/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
AOUN
Authorized Official First Name:
EDDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
313-525-2911

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 5301010531 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2146993 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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