Provider Demographics
NPI:1578905147
Name:MAPLE LEAF COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:MAPLE LEAF COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RESPONSIBLE PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:JERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:614-272-6791
Mailing Address - Street 1:2575 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-3333
Mailing Address - Country:US
Mailing Address - Phone:614-272-6791
Mailing Address - Fax:614-272-6826
Practice Address - Street 1:2575 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3333
Practice Address - Country:US
Practice Address - Phone:614-272-6791
Practice Address - Fax:614-272-6826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0223251503336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH022325150OtherOHIO STATE BOARD OF PHARMACY LICENSE