Provider Demographics
NPI:1043225683
Name:DAYTON OSTEOPATHIC HOSPITAL
Entity Type:Organization
Organization Name:DAYTON OSTEOPATHIC HOSPITAL
Other - Org Name:KHN PHARMACY BEAVERCREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-458-4932
Mailing Address - Street 1:4301 LYONS RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6446
Mailing Address - Country:US
Mailing Address - Phone:937-458-4934
Mailing Address - Fax:937-522-7198
Practice Address - Street 1:2510 COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3820
Practice Address - Country:US
Practice Address - Phone:937-558-3030
Practice Address - Fax:937-558-3089
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAYTON OSTEOPATHIC HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHPMY.021561900-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2645043Medicaid
OH2645043Medicaid