Provider Demographics
NPI:1144390220
Name:WILLARD FOODS INC
Entity Type:Organization
Organization Name:WILLARD FOODS INC
Other - Org Name:PLYMOUTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRIETEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-687-5332
Mailing Address - Street 1:262 SANDUSKY ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:44865-1151
Mailing Address - Country:US
Mailing Address - Phone:419-687-5332
Mailing Address - Fax:419-687-7685
Practice Address - Street 1:262 SANDUSKY ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:OH
Practice Address - Zip Code:44865-1151
Practice Address - Country:US
Practice Address - Phone:419-687-5332
Practice Address - Fax:419-687-7685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0219506003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3623813OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0503262Medicaid