Provider Demographics
NPI:1518170323
Name:THE CLEVELAND CLINIC FOUNDATION
Entity Type:Organization
Organization Name:THE CLEVELAND CLINIC FOUNDATION
Other - Org Name:CLEVELAND CLINIC NORTH COAST CANCER CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-973-3321
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:JJ10
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:419-609-2845
Mailing Address - Fax:419-609-2869
Practice Address - Street 1:417 QUARRY LAKES DR
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-8635
Practice Address - Country:US
Practice Address - Phone:419-609-2845
Practice Address - Fax:419-609-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0221730003336C0002X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2734189Medicaid
2133727OtherPK