1457399131 NPI number — DBA EAST MAIN STREET PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457399131 NPI number — DBA EAST MAIN STREET PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DBA EAST MAIN STREET PHARMACY
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:
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:
1457399131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1336 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43205-2081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-252-1998
Provider Business Mailing Address Fax Number:
614-252-3910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1336 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43205-2081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-252-1998
Provider Business Practice Location Address Fax Number:
614-252-3910
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLETCHER
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
OWNER AND CHIEF PHARMACIST
Authorized Official Telephone Number:
614-252-1998

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  021074900 , 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: 021074900 . This is a "STATE PHARMACY LICENSE NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3665582 . This is a "NABP NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2059356 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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