Provider Demographics
NPI:1437285350
Name:UPCO, LTD
Entity Type:Organization
Organization Name:UPCO, LTD
Other - Org Name:CEDARFAIRMOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CARYER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:216-795-1030
Mailing Address - Street 1:2458 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3131
Mailing Address - Country:US
Mailing Address - Phone:216-795-1030
Mailing Address - Fax:216-795-1712
Practice Address - Street 1:2458 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44106-3131
Practice Address - Country:US
Practice Address - Phone:216-795-1030
Practice Address - Fax:216-795-1712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-838700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0171291Medicaid
3619559OtherNABP
OH0171291Medicaid