Provider Demographics
NPI:1114021177
Name:LOUISVILLE PHARMACY INC
Entity Type:Organization
Organization Name:LOUISVILLE PHARMACY INC
Other - Org Name:MEDICINE CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:330-339-4466
Mailing Address - Street 1:2523 TUSCARAWAS ST W
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4701
Mailing Address - Country:US
Mailing Address - Phone:330-453-4804
Mailing Address - Fax:330-453-7688
Practice Address - Street 1:700 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1338
Practice Address - Country:US
Practice Address - Phone:330-875-5525
Practice Address - Fax:330-875-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
OH0205576503336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0713660Medicaid
2070772OtherPK
0455530001Medicare NSC