Provider Demographics
NPI:1689659369
Name:FAMILY PHARMACY
Entity Type:Organization
Organization Name:FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:D
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-592-2826
Mailing Address - Street 1:124 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2052
Mailing Address - Country:US
Mailing Address - Phone:937-592-2826
Mailing Address - Fax:937-592-0913
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2052
Practice Address - Country:US
Practice Address - Phone:937-592-2826
Practice Address - Fax:937-592-0913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020759050333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0945615Medicaid
3616692OtherNABPT
OH0945615Medicaid