Healthcare Provider Details

I. General information

NPI: 1144130071
Provider Name (Legal Business Name): THIRD STREET COMMUNITY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 E MAIN ST
SHELBY OH
44875-1262
US

IV. Provider business mailing address

1404 PARK AVE W STE 2
ONTARIO OH
44906-2719
US

V. Phone/Fax

Practice location:
  • Phone: 419-525-6729
  • Fax: 419-730-3590
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PEGGY ANDERSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 419-526-7880