Healthcare Provider Details

I. General information

NPI: 1689743320
Provider Name (Legal Business Name): YOURX STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 S MAIN STREET
MARENGO OH
43334
US

IV. Provider business mailing address

PO BOX 47
MARENGO OH
43334-0047
US

V. Phone/Fax

Practice location:
  • Phone: 419-253-3831
  • Fax:
Mailing address:
  • Phone: 419-253-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number020086300
License Number StateOH

VIII. Authorized Official

Name: LARRY HILDEBRAND
Title or Position: OWNER
Credential:
Phone: 419-253-3831