Provider Demographics
NPI:1053497354
Name:MAIN STREET MEDS LLC
Entity Type:Organization
Organization Name:MAIN STREET MEDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:740-695-1191
Mailing Address - Street 1:110 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-1225
Mailing Address - Country:US
Mailing Address - Phone:740-695-0786
Mailing Address - Fax:740-695-9968
Practice Address - Street 1:110 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-1225
Practice Address - Country:US
Practice Address - Phone:740-695-0786
Practice Address - Fax:740-695-9968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-29
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2701740Medicaid
OH2701740Medicaid
5791880001Medicare NSC