Healthcare Provider Details

I. General information

NPI: 1871667253
Provider Name (Legal Business Name): KETTERING MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

4301 LYONS RD
MIAMISBURG OH
45342-6446
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-8171
  • Fax: 937-395-8382
Mailing address:
  • Phone: 937-458-4932
  • Fax: 937-522-7198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number02051850
License Number StateOH

VIII. Authorized Official

Name: MR. KEVIN BLACKBURN
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 937-458-4932