MEDICARE: CHURCH SQUARE PHARMACY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	RTP02242760003	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2145685	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053727545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHURCH SQUARE PHARMACY INC.

Provider Business Mailing Address
First Line	:	14529 PURITAS AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-2813
Country	:	US
Telephone Number	:	216-476-1400
Fax Number	:	216-476-1401

Provider Business Practice Location Address
First Line	:	14529 PURITAS AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-2813
Country	:	US
Telephone Number	:	216-476-1400
Fax Number	:	216-476-1401

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ABDEL ABUKHALIL
Credential	:
Telephone Number	:	216-288-0557

Provider Enumeration Date	:	07/07/2014
Last Update Date	:	04/22/2025

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