Provider Demographics
NPI:1548334063
Name:PGPA LLC
Entity type:Organization
Organization Name:PGPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADRIANROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-381-7472
Mailing Address - Street 1:3544 MERIDIAN CROSSINGS
Mailing Address - Street 2:STE 120
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6025
Mailing Address - Country:US
Mailing Address - Phone:517-381-7472
Mailing Address - Fax:517-381-8724
Practice Address - Street 1:3544 MERIDIAN CROSSINGS
Practice Address - Street 2:STE 120
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6025
Practice Address - Country:US
Practice Address - Phone:517-381-7472
Practice Address - Fax:517-381-8724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010066023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043986OtherPK
MI3368731Medicaid
MI00668987Medicaid