Provider Demographics
NPI:1942690698
Name:ADENA PHARMACY LLC
Entity Type:Organization
Organization Name:ADENA PHARMACY LLC
Other - Org Name:ADENA PIKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-779-8761
Mailing Address - Street 1:100 DAWN LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9138
Mailing Address - Country:US
Mailing Address - Phone:740-947-6376
Mailing Address - Fax:
Practice Address - Street 1:100 DAWN LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9138
Practice Address - Country:US
Practice Address - Phone:740-947-6320
Practice Address - Fax:740-947-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTPC.022492650-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0164501Medicaid
2150099OtherPK