Provider Demographics
NPI:1871254599
Name:WYANDOT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WYANDOT MEMORIAL HOSPITAL
Other - Org Name:KOEHLER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-294-4991
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1098
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:425 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1038
Practice Address - Country:US
Practice Address - Phone:419-294-1916
Practice Address - Fax:419-294-0087
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYANDOT MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9687512Medicaid