Healthcare Provider Details

I. General information

NPI: 1306081385
Provider Name (Legal Business Name): MARC QUEEN R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N HIGH ST
HILLSBORO OH
45133-1132
US

IV. Provider business mailing address

421 N HIGH ST
HILLSBORO OH
45133-1132
US

V. Phone/Fax

Practice location:
  • Phone: 937-393-1734
  • Fax: 937-393-2421
Mailing address:
  • Phone: 937-393-1734
  • Fax: 937-393-2421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03221302
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: