Provider Demographics
NPI:1467738732
Name:CHURCH SQUARE PHARMACY INC.
Entity Type:Organization
Organization Name:CHURCH SQUARE PHARMACY INC.
Other - Org Name:ST. LUKE'S LOWCOST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ABDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUKHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-288-0557
Mailing Address - Street 1:11201 SHAKER BLVD STE 126
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3833
Mailing Address - Country:US
Mailing Address - Phone:216-795-4000
Mailing Address - Fax:216-795-4001
Practice Address - Street 1:11201 SHAKER BLVD STE 126
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3833
Practice Address - Country:US
Practice Address - Phone:216-795-4000
Practice Address - Fax:216-795-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH022165800333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
6351520003Medicare NSC