Provider Demographics
NPI:1053487694
Name:DAYTON MALL FOODS LLC
Entity Type:Organization
Organization Name:DAYTON MALL FOODS LLC
Other - Org Name:CUB PHARMACY 609
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-431-1662
Mailing Address - Street 1:8245 SPRINGBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6103
Mailing Address - Country:US
Mailing Address - Phone:937-439-0452
Mailing Address - Fax:937-434-0545
Practice Address - Street 1:8245 SPRINGBORO PIKE
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-6103
Practice Address - Country:US
Practice Address - Phone:937-434-5778
Practice Address - Fax:937-434-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
OHRTP0209410003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0271147Medicaid
3662459OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0271147Medicaid