Healthcare Provider Details

I. General information

NPI: 1669213385
Provider Name (Legal Business Name): MEDINA FAMILY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 MEDINA RD STE C
MEDINA OH
44256-6616
US

IV. Provider business mailing address

3705 MEDINA RD STE C
MEDINA OH
44256-6616
US

V. Phone/Fax

Practice location:
  • Phone: 330-486-8396
  • Fax: 888-905-4906
Mailing address:
  • Phone: 330-486-8396
  • Fax: 888-905-4906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN KOMARA III
Title or Position: OWNER/PRESIDENT
Credential: PHARMD
Phone: 304-868-3963