Provider Demographics
NPI:1689743320
Name:YOURX STORE INC
Entity Type:Organization
Organization Name:YOURX STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HILDEBRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-253-3831
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:OH
Mailing Address - Zip Code:43334-0047
Mailing Address - Country:US
Mailing Address - Phone:419-253-3831
Mailing Address - Fax:
Practice Address - Street 1:27 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:OH
Practice Address - Zip Code:43334
Practice Address - Country:US
Practice Address - Phone:419-253-3831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020086300333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0288915Medicaid
OH0744180001Medicare ID - Type Unspecified