Healthcare Provider Details

I. General information

NPI: 1710055959
Provider Name (Legal Business Name): COUNTY LINEPROFESSIONAL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 HIGH ST
WORTHINGTON OH
43085-4014
US

IV. Provider business mailing address

1020 HIGH ST
WORTHINGTON OH
43085-4014
US

V. Phone/Fax

Practice location:
  • Phone: 614-865-2577
  • Fax: 614-882-9546
Mailing address:
  • Phone: 614-865-2577
  • Fax: 614-882-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number021418350
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SCOTT PODOLAN
Title or Position: OWNER AND PHARMACIST
Credential: RPH
Phone: 614-865-2577