Provider Demographics
NPI:1740217678
Name:PROMEDICA PHARMACY GROUP LLC
Entity Type:Organization
Organization Name:PROMEDICA PHARMACY GROUP LLC
Other - Org Name:PROMEDICA OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:COEHRS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD RPH
Authorized Official - Phone:419-291-4496
Mailing Address - Street 1:2100 W. CENTRAL AVE
Mailing Address - Street 2:STE 140
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606
Mailing Address - Country:US
Mailing Address - Phone:419-291-4496
Mailing Address - Fax:419-214-4350
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-5418
Practice Address - Fax:419-479-6927
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROMEDICA CONTINUUM SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-27
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336I0012X, 3336S0011X
OH0205414503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0719468Medicaid
3643928OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH6366510009Medicare NSC