Provider Demographics
NPI:1376660746
Name:CAMPBELL PHARMACY INC
Entity Type:Organization
Organization Name:CAMPBELL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATISI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-755-5221
Mailing Address - Street 1:135 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:OH
Mailing Address - Zip Code:44405-1663
Mailing Address - Country:US
Mailing Address - Phone:330-755-5221
Mailing Address - Fax:330-755-1490
Practice Address - Street 1:135 12TH ST
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:OH
Practice Address - Zip Code:44405-1663
Practice Address - Country:US
Practice Address - Phone:330-755-5221
Practice Address - Fax:330-755-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0201499503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074370OtherPK
OH0403012Medicaid
3616945OtherOTHER ID NUMBER