Provider Demographics
NPI:1376612119
Name:HEALTHSOURCE OF OHIO INC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF OHIO INC
Other - Org Name:HEALTHSOURCE SEAMAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY OPS
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROTUNNA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:513-732-5084
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-707-4041
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:218 STERN RD
Practice Address - Street 2:
Practice Address - City:SEAMAN
Practice Address - State:OH
Practice Address - Zip Code:45679-9607
Practice Address - Country:US
Practice Address - Phone:937-386-0049
Practice Address - Fax:937-386-0230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-1220950333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2174614Medicaid
OH0831310002Medicare PIN