Provider Demographics
NPI:1669728473
Name:PHARMACY SPECIALTY GROUP, LLC
Entity type:Organization
Organization Name:PHARMACY SPECIALTY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:COURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-390-5830
Mailing Address - Street 1:6910 TREELINE DR STE G
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3366
Mailing Address - Country:US
Mailing Address - Phone:440-623-7100
Mailing Address - Fax:
Practice Address - Street 1:6910 TREELINE DR STE G
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141
Practice Address - Country:US
Practice Address - Phone:440-623-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 0222162503336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSP 022216250OtherPHARMACY LICENSE
OH6885520001Medicare NSC