Provider Demographics
NPI:1073724522
Name:LICKING MEMORIAL HEALTH SYSTEMS
Entity Type:Organization
Organization Name:LICKING MEMORIAL HEALTH SYSTEMS
Other - Org Name:LICKING MEMORIAL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTAGNESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4000
Mailing Address - Street 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-4545
Mailing Address - Fax:220-564-4546
Practice Address - Street 1:1320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-4545
Practice Address - Fax:220-564-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-10950503336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy