Provider Demographics
NPI:1205005063
Name:KETTERING MEDICAL CENTER
Entity Type:Organization
Organization Name:KETTERING MEDICAL CENTER
Other - Org Name:COLLABORATIVE PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-458-4932
Mailing Address - Street 1:4301 LYONS RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342
Mailing Address - Country:US
Mailing Address - Phone:937-458-4949
Mailing Address - Fax:937-458-4942
Practice Address - Street 1:4301 LYONS RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-458-4949
Practice Address - Fax:937-458-4942
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETTERING MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-26
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408149Medicaid
2081107OtherPK
OH0232000177OtherOH BOARD OF PHARMACY LIC.