Provider Demographics
NPI:1669493623
Name:MEDICAL UNIVERSITY OF OHIO AT TOLEDO
Entity Type:Organization
Organization Name:MEDICAL UNIVERSITY OF OHIO AT TOLEDO
Other - Org Name:UNIV OF TOLEDO MAIN CAMPUS OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-530-3471
Mailing Address - Street 1:2801 W BANCROFT ST # MS 513
Mailing Address - Street 2:VALERIE HOUSEHOLDER
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3328
Mailing Address - Country:US
Mailing Address - Phone:419-530-3471
Mailing Address - Fax:419-530-3473
Practice Address - Street 1:2801 W BANCROFT ST # MS 513
Practice Address - Street 2:VALERIE HOUSEHOLDER
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3328
Practice Address - Country:US
Practice Address - Phone:419-530-3471
Practice Address - Fax:419-530-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
OH0202575003336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0857872Medicaid
2072412OtherPK