Healthcare Provider Details

I. General information

NPI: 1013106202
Provider Name (Legal Business Name): FIELDS FAMILY ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E ALEX BELL RD STE 172
CENTERVILLE OH
45459-2752
US

IV. Provider business mailing address

415 S MAIN ST
WAYNESVILLE OH
45068-9553
US

V. Phone/Fax

Practice location:
  • Phone: 937-221-9240
  • Fax: 937-795-3291
Mailing address:
  • Phone: 513-897-7076
  • Fax: 513-897-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number021741050
License Number StateOH

VIII. Authorized Official

Name: DR. JORDAN MARK MULLINS
Title or Position: PIC, DIRECTOR OF PHARMACY
Credential: PHARMD
Phone: 513-600-8236