Provider Demographics
NPI:1174630461
Name:SCHWIETERMAN'S DRUG STORE INC
Entity Type:Organization
Organization Name:SCHWIETERMAN'S DRUG STORE INC
Other - Org Name:SCHWIETERMAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:DOMINIK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-629-2336
Mailing Address - Street 1:1302 DEFIANCE ST
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-1081
Mailing Address - Country:US
Mailing Address - Phone:419-738-5959
Mailing Address - Fax:419-738-3019
Practice Address - Street 1:1302 DEFIANCE ST
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-1081
Practice Address - Country:US
Practice Address - Phone:419-738-5959
Practice Address - Fax:419-738-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-3850503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0569880Medicaid
OH0569880Medicaid