Provider Demographics
NPI:1376955914
Name:PROFESSIONALS PRN LLC
Entity Type:Organization
Organization Name:PROFESSIONALS PRN LLC
Other - Org Name:NORTHSIDE HOME INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:STICKRATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-454-5666
Mailing Address - Street 1:21 N MAYSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-6110
Mailing Address - Country:US
Mailing Address - Phone:740-452-2447
Mailing Address - Fax:740-452-1399
Practice Address - Street 1:21 N MAYSVILLE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-6110
Practice Address - Country:US
Practice Address - Phone:740-452-2447
Practice Address - Fax:740-452-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0210685503336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2056902Medicaid
2145998OtherPK
2145998OtherPK