Provider Demographics
NPI:1437488558
Name:ADENA PHARMACY LLC
Entity Type:Organization
Organization Name:ADENA PHARMACY LLC
Other - Org Name:ADENA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:740-779-8761
Mailing Address - Street 1:272 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-8761
Mailing Address - Fax:740-779-8769
Practice Address - Street 1:272 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9031
Practice Address - Country:US
Practice Address - Phone:740-779-8761
Practice Address - Fax:740-779-8769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-19
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0221358503336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066701Medicaid
3678628OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0066701Medicaid