Healthcare Provider Details

I. General information

NPI: 1932770690
Provider Name (Legal Business Name): ETHAN LAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W SYCAMORE ST
COLUMBUS OH
43215-5618
US

IV. Provider business mailing address

150 W SYCAMORE ST
COLUMBUS OH
43215-5618
US

V. Phone/Fax

Practice location:
  • Phone: 614-340-7980
  • Fax:
Mailing address:
  • Phone: 614-340-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03439915
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: