Provider Demographics
NPI:1659459162
Name:MEDISERV SHORT NORTH PHCY INC
Entity Type:Organization
Organization Name:MEDISERV SHORT NORTH PHCY INC
Other - Org Name:MEDISERV SHORT NORTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-481-4272
Mailing Address - Street 1:21 W HUBBARD AVE
Mailing Address - Street 2:STE B
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 W HUBBARD AVE
Practice Address - Street 2:STE B
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1474
Practice Address - Country:US
Practice Address - Phone:614-294-6231
Practice Address - Fax:614-294-6223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
OH3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2605701Medicaid
3673779OtherOTHER ID NUMBER-COMMERCIAL NUMBER