Provider Demographics
NPI:1417015538
Name:DONALD C FILLMORE
Entity Type:Organization
Organization Name:DONALD C FILLMORE
Other - Org Name:FILLMORE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARM
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:FILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-927-2691
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:OH
Mailing Address - Zip Code:44882-0107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 S SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:OH
Practice Address - Zip Code:44882-0107
Practice Address - Country:US
Practice Address - Phone:419-927-2691
Practice Address - Fax:419-927-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP021791503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3638826OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0479496Medicaid
OH0479496Medicaid