Provider Demographics
NPI:1376657262
Name:MIKE TELL CHAR INC
Entity Type:Organization
Organization Name:MIKE TELL CHAR INC
Other - Org Name:BASSETT'S MARKET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST, AO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERBER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-732-6300
Mailing Address - Street 1:3994 E HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-2671
Mailing Address - Country:US
Mailing Address - Phone:419-732-6300
Mailing Address - Fax:419-734-4063
Practice Address - Street 1:3994 E HARBOR RD
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2671
Practice Address - Country:US
Practice Address - Phone:419-732-6300
Practice Address - Fax:419-734-4063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0205873003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0739491Medicaid
2071108OtherPK