1417015538 NPI number — DONALD C FILLMORE

Table of content: (NPI 1417015538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417015538 NPI number — DONALD C FILLMORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DONALD C FILLMORE
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:
Provider Other Organization Name Type Code:
6
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:
1417015538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYCAMORE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44882-0107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 S SYCAMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYCAMORE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44882-0107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-927-2691
Provider Business Practice Location Address Fax Number:
419-927-2681
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FILLMORE
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND PHARM
Authorized Official Telephone Number:
419-927-2691

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: RTP02179150 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3638826 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0479496 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com