Provider Demographics
NPI: | 1508174350 |
---|---|
Name: | IHS PHARMACY & WELLNESS CENTER |
Entity Type: | Organization |
Organization Name: | IHS PHARMACY & WELLNESS CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PHARMACY MANAGER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | TODD |
Authorized Official - Middle Name: | ALLEN |
Authorized Official - Last Name: | TACKAGE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 740-572-1561 |
Mailing Address - Street 1: | 4940 COTTONVILLE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | JAMESTOWN |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45335-1522 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 937-675-6500 |
Mailing Address - Fax: | 937-675-6540 |
Practice Address - Street 1: | 4940 COTTONVILLE RD |
Practice Address - Street 2: | |
Practice Address - City: | JAMESTOWN |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45335-1522 |
Practice Address - Country: | US |
Practice Address - Phone: | 937-675-6500 |
Practice Address - Fax: | 937-675-6540 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-09-15 |
Last Update Date: | 2010-09-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 022075950 | 3336C0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |