Provider Demographics
NPI:1902275928
Name:CENTRAL PHARMACY - MLK LLC
Entity Type:Organization
Organization Name:CENTRAL PHARMACY - MLK LLC
Other - Org Name:CENTRAL PHARMACY - MLK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDAGATLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-992-5101
Mailing Address - Street 1:3500 S MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-4339
Mailing Address - Country:US
Mailing Address - Phone:517-574-5362
Mailing Address - Fax:517-574-5362
Practice Address - Street 1:3500 S MLK BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-4339
Practice Address - Country:US
Practice Address - Phone:517-574-5015
Practice Address - Fax:517-574-5362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010107263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154108OtherPK
MI2381060Medicaid