Provider Demographics
NPI:1346388378
Name:CHILDREN'S HOSPITAL MEDICAL CENTER
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL MEDICAL CENTER
Other - Org Name:CHILDREN'S HOSPITAL MEDICAL CENTER - RETAIL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:SR DIRECTOR BILLING & CODING SERV
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-636-5047
Mailing Address - Street 1:3337 SOLUTIONS CENTER
Mailing Address - Street 2:BOX 773337
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3003
Mailing Address - Country:US
Mailing Address - Phone:513-636-4225
Mailing Address - Fax:513-636-2511
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3039
Practice Address - Country:US
Practice Address - Phone:513-636-4225
Practice Address - Fax:513-636-2511
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOSPITAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-00404003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54021670Medicaid
IN200046400AMedicaid
WV0173998003Medicaid
OH02-32000233OtherLICENSE
OH2800017Medicaid
3629219OtherNCPDP
3629219OtherNCPDP
1125280002Medicare NSC