Basic Information
| Provider Information | |||||||||
| NPI: | 1780608315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER WELLS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | KAISER WELLS PHARMACY AND HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 251 BENEDICT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448572346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196687651 | ||||||||
| FaxNumber: | 4196635837 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 BENEDICT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448572346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196687651 | ||||||||
| FaxNumber: | 4196635837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NESTOR | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4196687651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.PH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | HMER.22043 | OH | X | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | OH | X | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 03501 | 01 | OH | PARAMOUNT HEALTHCARE | OTHER | 4511335 | 05 | OH | MEDICAID | 56129 | 01 | OH | ABP | OTHER | 56129 | 01 | OH | NORTHWOOD NPN | OTHER | 000000155940 | 01 | UNICARE | OTHER | 000000155940 | 01 | OH | ANTHEM BCBS | OTHER | 4511335 | 01 | OH | BCMH | OTHER |