Provider Demographics
NPI:1295857498
Name:AULTMAN PHARMACY INC
Entity Type:Organization
Organization Name:AULTMAN PHARMACY INC
Other - Org Name:AULTMAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHRM MANG
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-433-9005
Mailing Address - Street 1:5215 FULTON DR NW # WN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5215 FULTON DR NW # WN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1805
Practice Address - Country:US
Practice Address - Phone:330-433-9005
Practice Address - Fax:330-433-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0216736003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3675773OtherOTHER ID NUMBER
OH2721022Medicaid
3675773OtherOTHER ID NUMBER