Provider Demographics
NPI:1922143551
Name:LALLY DRUG INC
Entity Type:Organization
Organization Name:LALLY DRUG INC
Other - Org Name:LALLY HEALTH MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LALLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-631-3785
Mailing Address - Street 1:23 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 ERIE RD
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2326
Practice Address - Country:US
Practice Address - Phone:330-633-3239
Practice Address - Fax:330-633-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
OH021664150005103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2719599Medicaid
3675658OtherOTHER ID NUMBER
3675658OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3675658OtherOTHER ID NUMBER-COMMERCIAL NUMBER