=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205385333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPTOWN PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2016
-----------------------------------------------------
Last Update Date | 07/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 73 SPORTSMAN DR SUITE B
-----------------------------------------------------
City | MARENGO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43334-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-253-0632
-----------------------------------------------------
Fax | 419-253-0622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 SPORTSMAN DR SUITE B
-----------------------------------------------------
City | MARENGO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43334-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-253-0632
-----------------------------------------------------
Fax | 419-253-0622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DR. NICHOLAS WILLIAM NEWMAN
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 419-253-0732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 022629350
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 022629350
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 022629350
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------