Provider Demographics
NPI:1255883484
Name:HAWTHORNE PHARMACY LLC
Entity type:Organization
Organization Name:HAWTHORNE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-299-7967
Mailing Address - Street 1:3320 TYLERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-7714
Mailing Address - Country:US
Mailing Address - Phone:513-299-7967
Mailing Address - Fax:513-285-3147
Practice Address - Street 1:3320 TYLERSVILLE RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-7714
Practice Address - Country:US
Practice Address - Phone:513-299-7967
Practice Address - Fax:513-285-3147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP.022648650-03336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166145OtherPK