Provider Demographics
NPI:1720176878
Name:MERCY PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:MERCY PROFESSIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:C
Authorized Official - Last Name:REALE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-489-1400
Mailing Address - Street 1:1330 MERCY DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2626
Mailing Address - Country:US
Mailing Address - Phone:330-489-1400
Mailing Address - Fax:330-489-1175
Practice Address - Street 1:1330 MERCY DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2626
Practice Address - Country:US
Practice Address - Phone:330-489-1400
Practice Address - Fax:330-489-1175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-1142503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0405976Medicaid