Provider Demographics
NPI:1942213269
Name:MERCY MEDICAL PARTNERS NORTHERN REGION LLC
Entity Type:Organization
Organization Name:MERCY MEDICAL PARTNERS NORTHERN REGION LLC
Other - Org Name:MERCY DEFIANCE CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:INKROTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-783-3376
Mailing Address - Street 1:1400 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2440
Mailing Address - Country:US
Mailing Address - Phone:419-783-3376
Mailing Address - Fax:419-783-3378
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2440
Practice Address - Country:US
Practice Address - Phone:419-783-3376
Practice Address - Fax:419-783-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP0221699003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061418Medicaid
2133639OtherPK