Provider Demographics
NPI:1528193273
Name:FIRELANDS PHARMACY, INC.
Entity Type:Organization
Organization Name:FIRELANDS PHARMACY, INC.
Other - Org Name:VINTAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:LAPP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:440-967-3100
Mailing Address - Street 1:1605 STATE RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-9141
Mailing Address - Country:US
Mailing Address - Phone:440-967-3100
Mailing Address - Fax:
Practice Address - Street 1:1605 STATE RD
Practice Address - Street 2:SUITE 11
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-9141
Practice Address - Country:US
Practice Address - Phone:440-967-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03209606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0624677Medicaid
0962290001Medicare ID - Type UnspecifiedMEDICARE