Provider Demographics
NPI:1710998356
Name:PHARMISERV CORP
Entity Type:Organization
Organization Name:PHARMISERV CORP
Other - Org Name:MEDICAL PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEUER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:614-878-9665
Mailing Address - Street 1:5212 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1642
Mailing Address - Country:US
Mailing Address - Phone:614-878-9665
Mailing Address - Fax:614-878-4660
Practice Address - Street 1:5212 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1642
Practice Address - Country:US
Practice Address - Phone:614-878-9665
Practice Address - Fax:614-878-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0201503503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3634121OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0361460Medicaid