1336735901 NPI number — PHARMCO MANAGEMENT, LLC

Table of content: (NPI 1336735901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336735901 NPI number — PHARMCO MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMCO MANAGEMENT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMPOUNDING PHARMACY OF GREEN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336735901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
877 HIDDEN VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WADSWORTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44281-9282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-232-1255
Provider Business Mailing Address Fax Number:
330-899-0652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4016 MASSILLON RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIONTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44685-7818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-899-0406
Provider Business Practice Location Address Fax Number:
330-899-0652
Provider Enumeration Date:
12/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CARCIONE
Authorized Official First Name:
ROSARIO
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-899-0406

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1336735901 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0232000218 . This is a "LICENSE TO DISTRIBUTE DANGEROUS DRUGS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0426880 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3688554 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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