Provider Demographics
NPI:1184174682
Name:LICKING MEMORIAL HEALTH SYSTEM
Entity type:Organization
Organization Name:LICKING MEMORIAL HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICATION THERAPY CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STURGEON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:220-564-1898
Mailing Address - Street 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-1898
Mailing Address - Fax:220-564-1899
Practice Address - Street 1:1320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-1898
Practice Address - Fax:220-564-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03325440261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service