1578914040 NPI number — VIRTUS OHIO PHARMACY, LLC

Table of content: (NPI 1578914040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578914040 NPI number — VIRTUS OHIO PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRTUS OHIO PHARMACY, 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:
CENTERVILLE LTC PHARMACY
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:
1578914040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
947 W MONTANA ST APT 3E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60614-2429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-391-6845
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9352 LEBANON PIKE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45458-3843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-435-5751
Provider Business Practice Location Address Fax Number:
937-435-5759
Provider Enumeration Date:
06/27/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
RUTUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
312-391-6845

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  PSNH.022586600- , 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: 2160200 . This is a "PK" identifier . This identifiers is of the category "OTHER".