Provider Demographics
NPI:1073528907
Name:FRUTH PHARMACY OF OHIO INC
Entity Type:Organization
Organization Name:FRUTH PHARMACY OF OHIO INC
Other - Org Name:FRUTH PHARMACY 15
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-675-1612
Mailing Address - Street 1:FRUTH CORPORATE OFFICES
Mailing Address - Street 2:4016 OHIO RIVER ROAD
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550
Mailing Address - Country:US
Mailing Address - Phone:304-675-1612
Mailing Address - Fax:304-675-7338
Practice Address - Street 1:1401 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-2201
Practice Address - Country:US
Practice Address - Phone:740-423-9561
Practice Address - Fax:740-423-0139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0206905503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0854740Medicaid
WV1073528907Medicaid
WV0227766007Medicaid
2072393OtherPK
0469090005Medicare NSC