Provider Demographics
NPI:1053667204
Name:EMMANUEL VENTURES LIMITED LLC
Entity Type:Organization
Organization Name:EMMANUEL VENTURES LIMITED LLC
Other - Org Name:SEVERANCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:OPEYEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEWESO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:216-691-2369
Mailing Address - Street 1:4127 E 131ST ST
Mailing Address - Street 2:MILES SUPERMARKET
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5563
Mailing Address - Country:US
Mailing Address - Phone:216-691-2369
Mailing Address - Fax:216-691-3119
Practice Address - Street 1:4127 E 131ST ST
Practice Address - Street 2:MILES SUPERMARKET
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5563
Practice Address - Country:US
Practice Address - Phone:216-691-2369
Practice Address - Fax:216-691-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OHRTP.022607100-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136201OtherPK
6724950001Medicare NSC