Provider Demographics
NPI:1649379108
Name:MR PRESCRIPTION INC
Entity Type:Organization
Organization Name:MR PRESCRIPTION INC
Other - Org Name:CLARKS MR PRESCRIPTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-428-7970
Mailing Address - Street 1:7044 SOLUTION CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0001
Mailing Address - Country:US
Mailing Address - Phone:937-428-7970
Mailing Address - Fax:937-428-7978
Practice Address - Street 1:2601 S SMITHVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-2641
Practice Address - Country:US
Practice Address - Phone:937-253-3166
Practice Address - Fax:937-253-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH021813503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0477041Medicaid
3638422OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0179530001Medicare NSC