Provider Demographics
NPI:1780863639
Name:MERCY HEALTH YOUNGSTOWN LLC
Entity Type:Organization
Organization Name:MERCY HEALTH YOUNGSTOWN LLC
Other - Org Name:ST ELIZABETH BOARDMAN HEALTH CENTER PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHRODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-480-3570
Mailing Address - Street 1:8401 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6777
Mailing Address - Country:US
Mailing Address - Phone:330-729-2929
Mailing Address - Fax:
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6777
Practice Address - Country:US
Practice Address - Phone:330-729-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02123950333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH360276Medicare PIN