Healthcare Provider Details

I. General information

NPI: 1760199053
Provider Name (Legal Business Name): MADISON IMBODEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6235 MONROE ST
SYLVANIA OH
43560-1427
US

IV. Provider business mailing address

6810 WYNNBROOK CT
HOLLAND OH
43528-9623
US

V. Phone/Fax

Practice location:
  • Phone: 419-885-4738
  • Fax:
Mailing address:
  • Phone: 937-403-4479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03442197
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: