Provider Demographics
NPI:1134497175
Name:HYS HEALTH MART INC
Entity Type:Organization
Organization Name:HYS HEALTH MART INC
Other - Org Name:MEDICINE CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SALOUHA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:440-366-1035
Mailing Address - Street 1:403 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6143
Mailing Address - Country:US
Mailing Address - Phone:440-366-1035
Mailing Address - Fax:440-366-0028
Practice Address - Street 1:403 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6143
Practice Address - Country:US
Practice Address - Phone:440-366-1035
Practice Address - Fax:440-366-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP.0221775503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063260Medicaid
2132941OtherPK
OH0063260Medicaid