Provider Demographics
NPI:1700024213
Name:WESTERN RESERVE HOSPITAL, LLC
Entity Type:Organization
Organization Name:WESTERN RESERVE HOSPITAL, LLC
Other - Org Name:SUMMA WESTERN RESERVE HOSPITAL, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-971-7393
Mailing Address - Street 1:1900 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-1404
Mailing Address - Country:US
Mailing Address - Phone:330-971-7393
Mailing Address - Fax:330-971-7394
Practice Address - Street 1:1900 23RD ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1404
Practice Address - Country:US
Practice Address - Phone:330-971-7393
Practice Address - Fax:330-971-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OH0219654503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2964494Medicaid
2120779OtherPK