Provider Demographics
NPI:1326376310
Name:CHURCH SQUARE PHARMACY
Entity Type:Organization
Organization Name:CHURCH SQUARE PHARMACY
Other - Org Name:CLARK LOWCOST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUKHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-288-0557
Mailing Address - Street 1:3107 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1145
Mailing Address - Country:US
Mailing Address - Phone:216-651-8685
Mailing Address - Fax:216-651-8766
Practice Address - Street 1:3107 CLARK AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1145
Practice Address - Country:US
Practice Address - Phone:216-651-8685
Practice Address - Fax:216-651-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
OH0220041503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122864OtherPK
OH3013358Medicaid
6351520002Medicare NSC