Basic Information
| Provider Information | |||||||||
| NPI: | 1891009502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSOURCE OF OHIO INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTHSOURCE OF OHIO BATAVIA PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2055 HOSPITAL DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | BATAVIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451031964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137320700 | ||||||||
| FaxNumber: | 5137320642 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451031964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137320700 | ||||||||
| FaxNumber: | 5137320642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2010 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROTUNNA | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5137325084 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 02-2076650 | OH | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2126485 | 01 | PK | OTHER | 3077843 | 05 | OH | MEDICAID |