Provider Demographics
NPI:1235251802
Name:STANDARD PHARMACY
Entity Type:Organization
Organization Name:STANDARD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND RPH
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-325-2224
Mailing Address - Street 1:541 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504
Mailing Address - Country:US
Mailing Address - Phone:937-325-2224
Mailing Address - Fax:937-325-0422
Practice Address - Street 1:541 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504
Practice Address - Country:US
Practice Address - Phone:937-325-2224
Practice Address - Fax:937-325-0422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020099350020493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH8371953Medicaid