Provider Demographics
NPI:1275999724
Name:LOWER LIGHTS PHARMACY
Entity Type:Organization
Organization Name:LOWER LIGHTS PHARMACY
Other - Org Name:LOWER LIGHTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-274-1455
Mailing Address - Street 1:1160 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1352
Mailing Address - Country:US
Mailing Address - Phone:614-274-1455
Mailing Address - Fax:
Practice Address - Street 1:1160 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1352
Practice Address - Country:US
Practice Address - Phone:614-274-1455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOWER LIGHTS CHRISTIAN HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH022580300-023336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0348534Medicaid