Provider Demographics
NPI:1689925356
Name:HEALTH PARTNERS OF WESTERN OHIO
Entity Type:Organization
Organization Name:HEALTH PARTNERS OF WESTERN OHIO
Other - Org Name:KENTON COMMUNITY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-222-1680
Mailing Address - Street 1:111 W ESPY ST
Mailing Address - Street 2:
Mailing Address - City:KENTON
Mailing Address - State:OH
Mailing Address - Zip Code:43326-2117
Mailing Address - Country:US
Mailing Address - Phone:419-679-5995
Mailing Address - Fax:419-679-1393
Practice Address - Street 1:111 W ESPY ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-2117
Practice Address - Country:US
Practice Address - Phone:419-679-5995
Practice Address - Fax:419-679-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
OH0222416503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137048OtherPK
OH0072656Medicaid