Provider Demographics
NPI:1629106984
Name:INDEPENDENT PHARMACY GROUP INC
Entity Type:Organization
Organization Name:INDEPENDENT PHARMACY GROUP INC
Other - Org Name:NORTH LIMA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-549-2620
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:11740 SOUTH AVE
Mailing Address - City:NORTH LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:44452-0301
Mailing Address - Country:US
Mailing Address - Phone:330-549-2620
Mailing Address - Fax:330-549-0042
Practice Address - Street 1:11740 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:NORTH LIMA
Practice Address - State:OH
Practice Address - Zip Code:44452-0301
Practice Address - Country:US
Practice Address - Phone:330-549-2620
Practice Address - Fax:330-549-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21277850333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0718772Medicaid
3623522OtherOTHER ID NUMBER-COMMERCIAL NUMBER