Provider Demographics
NPI:1578700399
Name:P & R HOME IV SERVICE INC
Entity Type:Organization
Organization Name:P & R HOME IV SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:FARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-587-3349
Mailing Address - Street 1:16937 DEFIANCE TRAIL
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891
Mailing Address - Country:US
Mailing Address - Phone:800-587-7670
Mailing Address - Fax:419-587-3229
Practice Address - Street 1:16937 DEFIANCE TRAIL
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891
Practice Address - Country:US
Practice Address - Phone:800-587-7670
Practice Address - Fax:419-587-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02434900333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH340835023003OtherMEDICAL MUTUAL OF OHIODME
OH0631301Medicaid
OH53234OtherNORTHWOOD NPN
OH000000155895OtherANTHEM DME
OH000000224193OtherANTHEM IV
OH0631301Medicaid
OH340835023003OtherMEDICAL MUTUAL OF OHIODME