Healthcare Provider Details

I. General information

NPI: 1568921054
Provider Name (Legal Business Name): TRENTON SOUKUP PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

IV. Provider business mailing address

805 BOBCAT AVE STE 406
GRANDVIEW HEIGHTS OH
43212-3895
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-9199
  • Fax:
Mailing address:
  • Phone: 740-391-9851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03337337
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: