Provider Demographics
NPI:1790859171
Name:KETTERING MEDICAL CENTER
Entity Type:Organization
Organization Name:KETTERING MEDICAL CENTER
Other - Org Name:KHN PHARMACY SYCAMORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-458-4932
Mailing Address - Street 1:4301 LYONS RD.
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342
Mailing Address - Country:US
Mailing Address - Phone:937-458-4934
Mailing Address - Fax:937-522-7198
Practice Address - Street 1:4000 MIAMISBURG-CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-384-3868
Practice Address - Fax:937-384-3868
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETTERING MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
OH0210766503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2085818Medicaid
3666039OtherOTHER ID NUMBER
OH2805818Medicaid