Provider Demographics
NPI:1699391730
Name:CLOUSE, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CLOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JAMESON CRANE SPORTS MEDICINE INSTITUTE PHARMACY
Mailing Address - Street 2:2835 FRED TAYLOR DRIVE
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:JAMESON CRANE SPORTS MEDICINE INSTITUTE PHARMACY
Practice Address - Street 2:2835 FRED TAYLOR DRIVE
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202
Practice Address - Country:US
Practice Address - Phone:614-366-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03331153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist