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General NPI Number Information
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NPI Number | 1295879369
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Entity Type | Organization
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Legal Business Name | MADISON AVENUE PHARMACY
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 640 N FOUNTAIN AVE
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City | SPRINGFIELD
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State | OH
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Zip | 45504-2202
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Country | US
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Telephone | 937-323-1841
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Fax | 937-323-1016
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Provider Business Mailing Address
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Address Line | 640 N FOUNTAIN AVE
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City | SPRINGFIELD
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State | OH
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Zip | 45504-2202
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Country | US
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Telephone | 937-323-1841
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Fax | 937-323-1016
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Authorized Official
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Title or Position | PEDORTHIST
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Name | MRS. GINGER LYNNETTE HENNIG
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Credential | L.PED.
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Telephone | 937-788-2402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | LPED110
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License Number State | OH
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