Basic Information
Provider Information | |||||||||
NPI: | 1225549819 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHARMACY COUNTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2655 W CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436063550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4194731493 | ||||||||
FaxNumber: | 4194747137 | ||||||||
Practice Location | |||||||||
Address1: | 2005 E 28TH ST STE 2 | ||||||||
Address2: |   | ||||||||
City: | LORAIN | ||||||||
State: | OH | ||||||||
PostalCode: | 440551908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402778922 | ||||||||
FaxNumber: | 4402770641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2017 | ||||||||
LastUpdateDate: | 04/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CROSS | ||||||||
AuthorizedOfficialFirstName: | MISSY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4194731473 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PROMEDICA PHYSICIAN GROUP, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
No ID Information.