Provider Demographics
NPI:1497842991
Name:GOOD SAMARITAN OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:GOOD SAMARITAN OUTPATIENT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KAES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:513-872-3550
Mailing Address - Street 1:375 DIXMYTH AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220
Mailing Address - Country:US
Mailing Address - Phone:513-872-1559
Mailing Address - Fax:513-475-5878
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220
Practice Address - Country:US
Practice Address - Phone:513-872-1559
Practice Address - Fax:513-475-5878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0200306503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH020030650OtherTERMINAL DISTRIBUTER
OH2312867Medicaid
OH3661851OtherNCPDP