Provider Demographics
NPI:1366816043
Name:SOUTHERN OHIO MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHERN OHIO MEDICAL CENTER
Other - Org Name:SOMC PHARMACY WHEELERSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY/RESPIRATORY SE
Authorized Official - Prefix:
Authorized Official - First Name:RORY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-574-8933
Mailing Address - Street 1:1805 27TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2640
Mailing Address - Country:US
Mailing Address - Phone:740-356-8193
Mailing Address - Fax:
Practice Address - Street 1:8770 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1918
Practice Address - Country:US
Practice Address - Phone:740-574-8933
Practice Address - Fax:740-356-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHPMY.022572900-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0153224Medicaid
2155191OtherPK