Provider Demographics
NPI:1134568504
Name:NEIDIG PHARMACY GROUP LLC
Entity type:Organization
Organization Name:NEIDIG PHARMACY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:NEIDIG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:740-492-0191
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-0190
Mailing Address - Country:US
Mailing Address - Phone:740-492-0191
Mailing Address - Fax:740-492-0275
Practice Address - Street 1:415 S RIVER ST
Practice Address - Street 2:
Practice Address - City:NEWCOMERSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43832-1443
Practice Address - Country:US
Practice Address - Phone:740-492-0191
Practice Address - Fax:740-492-0275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0222838003336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0087538Medicaid
OH7040970001Medicare NSC