Provider Demographics
NPI:1538424858
Name:CENTERLINE CITY PHARMACY LLC
Entity type:Organization
Organization Name:CENTERLINE CITY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHITTIPROLU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-635-8827
Mailing Address - Street 1:8033 E 10 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1427
Mailing Address - Country:US
Mailing Address - Phone:586-427-5344
Mailing Address - Fax:586-427-5589
Practice Address - Street 1:8033 E 10 MILE RD STE 103
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1454
Practice Address - Country:US
Practice Address - Phone:586-427-5344
Practice Address - Fax:586-427-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
MI53010098473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2376968OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6830130001Medicare NSC