Provider Demographics
NPI:1013090059
Name:THE CLEVELAND CLINIC FOUNDATION
Entity Type:Organization
Organization Name:THE CLEVELAND CLINIC FOUNDATION
Other - Org Name:FAIRVIEW HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-973-3321
Mailing Address - Street 1:9500 EUCLID AVE, JJ10
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195
Mailing Address - Country:US
Mailing Address - Phone:216-476-7119
Mailing Address - Fax:216-476-9905
Practice Address - Street 1:18101 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5612
Practice Address - Country:US
Practice Address - Phone:216-476-7119
Practice Address - Fax:216-476-9905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-01401003336C0002X
OH0201401003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2633565Medicaid
3632355OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH2633565Medicaid