MEDICARE: IMMUNIZATION SPECIALISTS OF OHIO

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	333600000X	Pharmacy

General Provider Information

NPI Number	:	1265869358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMUNIZATION SPECIALISTS OF OHIO

Provider Business Mailing Address
First Line	:	3999 LYDGATE DR
Second Line	:
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-1939
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3999 LYDGATE DR
Second Line	:
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-1939
Country	:	US
Telephone Number	:	440-520-0659
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL A SALEM
Credential	:	PHARMD
Telephone Number	:	440-520-0659

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	10/03/2013

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