Basic Information
| Provider Information | |||||||||
| NPI: | 1568784254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY COUNTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROMEDICAL HOME MEDICAL EQUIPMENT FOSTORIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 PARKWAY DR | ||||||||
| Address2: | |||||||||
| City: | FOSTORIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448301592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194360004 | ||||||||
| FaxNumber: | 4194368190 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 PARKWAY DR | ||||||||
| Address2: | |||||||||
| City: | FOSTORIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448301592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194360004 | ||||||||
| FaxNumber: | 4194368190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2010 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | GLADEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4198247427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROMEDICA CONTINUING CARE SERVICES INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 3099123 | 05 | OH | MEDICAID |