Provider Demographics
NPI:1588652135
Name:DECARIA BROTHERS, INC
Entity Type:Organization
Organization Name:DECARIA BROTHERS, INC
Other - Org Name:HERCHE-BLOOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUNO
Authorized Official - Middle Name:
Authorized Official - Last Name:DECARIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-385-0825
Mailing Address - Street 1:104 E FIFTH ST
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-3031
Mailing Address - Country:US
Mailing Address - Phone:330-385-0825
Mailing Address - Fax:330-385-8415
Practice Address - Street 1:104 E FIFTH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-3031
Practice Address - Country:US
Practice Address - Phone:330-385-0825
Practice Address - Fax:330-385-8415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020178800333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3621631OtherNABP
WV0143494000Medicaid
OH0475936Medicaid
OHFV94391Medicare PIN
3621631OtherNABP