Provider Demographics
NPI:1275906554
Name:CHAMPION DISCOUNT PHARMACY, LLC
Entity Type:Organization
Organization Name:CHAMPION DISCOUNT PHARMACY, LLC
Other - Org Name:CHAMPION DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER, LLC
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-219-3005
Mailing Address - Street 1:4299 MAHONING AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-1928
Mailing Address - Country:US
Mailing Address - Phone:234-806-3137
Mailing Address - Fax:234-806-3138
Practice Address - Street 1:4299 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-1928
Practice Address - Country:US
Practice Address - Phone:330-306-9616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0150213Medicaid
2154953OtherPK
2154953OtherPK