=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134568504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEIDIG PHARMACY GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2013
-----------------------------------------------------
Last Update Date | 05/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 S RIVER ST
-----------------------------------------------------
City | NEWCOMERSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43832-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-492-0191
-----------------------------------------------------
Fax | 740-492-0275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 190
-----------------------------------------------------
City | NEW PHILADELPHIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44663-0190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-492-0191
-----------------------------------------------------
Fax | 740-492-0275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. KEVIN H NEIDIG
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 740-492-0191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 022283800
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------