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General NPI Number Information
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NPI Number | 1184907115
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Entity Type | Organization
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Legal Business Name | PEMBERVILLE DRUG STORE LLC
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Dates
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Enumeration Date | 09/26/2011
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Last Update Date | 09/26/2011
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Provider Practice Location Address
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Address Line | 139 E FRONT ST # 897
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City | PEMBERVILLE
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State | OH
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Zip | 43450-7032
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Country | US
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Telephone | 419-287-3238
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Fax | 419-287-2008
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Provider Business Mailing Address
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Address Line | 139 E FRONT ST # 897
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City | PEMBERVILLE
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State | OH
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Zip | 43450-7032
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Country | US
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Telephone | 419-287-3238
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Fax | 419-287-2008
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOSEPH LEE BAUMGARTNER
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Credential | RPH
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Telephone | 419-287-3238
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 022122100
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License Number State | OH
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