Provider Demographics
NPI:1417926262
Name:KLASS APOTHECARY INC
Entity Type:Organization
Organization Name:KLASS APOTHECARY INC
Other - Org Name:TUCKERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLASS
Authorized Official - Suffix:
Authorized Official - Credentials:BS RPH
Authorized Official - Phone:937-477-9653
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:GLANDORF
Mailing Address - State:OH
Mailing Address - Zip Code:45848-0033
Mailing Address - Country:US
Mailing Address - Phone:419-538-7120
Mailing Address - Fax:419-538-7121
Practice Address - Street 1:105 DR THATYE DRIVE
Practice Address - Street 2:
Practice Address - City:GLANDORF
Practice Address - State:OH
Practice Address - Zip Code:45848
Practice Address - Country:US
Practice Address - Phone:419-538-7120
Practice Address - Fax:419-538-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0217561503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2781306Medicaid
3669314OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3669314OtherNCPDP PROVIDER IDENTIFICATION NUMBER