Basic Information
| Provider Information | |||||||||
| NPI: | 1811368210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH PARTNERS OF WESTERN OHIO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TIFFIN COMMUNITY HEALTH CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 486 W PERRY ST | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448831902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192221680 | ||||||||
| FaxNumber: | 4195495670 | ||||||||
| Practice Location | |||||||||
| Address1: | 486 W PERRY ST | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448831902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192221680 | ||||||||
| FaxNumber: | 4195495670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2015 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4192221680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH PARTNERS OF WESTERN OHIO | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.