Healthcare Provider Details

I. General information

NPI: 1215159892
Provider Name (Legal Business Name): WADE A KIRK RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 11/27/2023
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 INTEGRITY DR
HEBRON OH
43025-7013
US

IV. Provider business mailing address

96 INTEGRITY DR STE D
HEBRON OH
43025-7013
US

V. Phone/Fax

Practice location:
  • Phone: 740-928-3455
  • Fax:
Mailing address:
  • Phone: 740-928-3455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-3-20286
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: