Basic Information
Provider Information | |||||||||
NPI: | 1740217678 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROMEDICA PHARMACY GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMEDICA OUTPATIENT PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 W. CENTRAL AVE | ||||||||
Address2: | STE 140 | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 43606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192914496 | ||||||||
FaxNumber: | 4192144350 | ||||||||
Practice Location | |||||||||
Address1: | 2142 N COVE BLVD | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436063895 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192915418 | ||||||||
FaxNumber: | 4194796927 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2006 | ||||||||
LastUpdateDate: | 04/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COEHRS | ||||||||
AuthorizedOfficialFirstName: | BRYAN | ||||||||
AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
AuthorizedOfficialTelephone: | 4192914496 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PROMEDICA CONTINUUM SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARMD RPH | ||||||||
NPICertificationDate: | 04/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X |   |   | N |   | Suppliers | Pharmacy | Institutional Pharmacy | 3336S0011X |   |   | N |   | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 020541450 | OH | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 0719468 | 05 | OH |   | MEDICAID | 3643928 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |