Healthcare Provider Details

I. General information

NPI: 1811932049
Provider Name (Legal Business Name): MARYMOUNT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 MCCRACKEN RD STE 151
GARFIELD HEIGHTS OH
44125-2964
US

IV. Provider business mailing address

PO BOX 931783
CLEVELAND OH
44193-1884
US

V. Phone/Fax

Practice location:
  • Phone: 216-578-8822
  • Fax: 216-587-8844
Mailing address:
  • Phone: 216-445-2357
  • Fax: 216-445-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number021567350
License Number StateOH

VIII. Authorized Official

Name: MR. TIM LONGVILLE
Title or Position: CHIEF ACCOUNTING OFFICER AND CONTRO
Credential: MHA, RPH
Phone: 216-636-7416