Provider Demographics
NPI:1740502335
Name:SIGNATURE HEALTH INC
Entity type:Organization
Organization Name:SIGNATURE HEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-953-9999
Mailing Address - Street 1:38876 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094
Mailing Address - Country:US
Mailing Address - Phone:440-953-9999
Mailing Address - Fax:
Practice Address - Street 1:38876 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-953-9999
Practice Address - Fax:440-954-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
OH0214201503336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3042102Medicaid
2124315OtherPK
OH2325835Medicaid
OH3042102Medicaid