Provider Demographics
NPI:1972651933
Name:BETHANN PASSARELLO INC
Entity Type:Organization
Organization Name:BETHANN PASSARELLO INC
Other - Org Name:THE MEDICINE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BETHANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PASSARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:330-757-3553
Mailing Address - Street 1:6615 CLINGAN RD
Mailing Address - Street 2:STE B
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2196
Mailing Address - Country:US
Mailing Address - Phone:330-757-3553
Mailing Address - Fax:330-757-0155
Practice Address - Street 1:6615 CLINGAN RD
Practice Address - Street 2:STE B
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-2196
Practice Address - Country:US
Practice Address - Phone:330-757-3553
Practice Address - Fax:330-757-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP.021352850-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2075518OtherPK
3633674OtherOTHER ID NUMBER-COMMERCIAL NUMBER