Healthcare Provider Details

I. General information

NPI: 1013146950
Provider Name (Legal Business Name): IMMUNIZATION CONSULTANTS OF CENTRAL OHIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W CHERRY ST SUITE 129
SUNBURY OH
43074-8573
US

IV. Provider business mailing address

801 W CHERRY ST SUITE 129
SUNBURY OH
43074-8573
US

V. Phone/Fax

Practice location:
  • Phone: 614-214-0128
  • Fax:
Mailing address:
  • Phone: 614-214-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number021988950
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number021988950-12
License Number StateOH

VIII. Authorized Official

Name: DANIEL S WILLIAMS
Title or Position: MEMBER
Credential: PHARM.D.
Phone: 614-214-0128