=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356808299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRAGONFLY HOSPICE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2019
-----------------------------------------------------
Last Update Date | 02/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5075 WINDFALL RD # 253
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-8613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-952-1011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 264 SMITH TOWNSHIP STATE RD STE 5
-----------------------------------------------------
City | BURGETTSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15021-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-414-1425
-----------------------------------------------------
Fax | 855-445-4203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PHARMACY OPERATIONS
-----------------------------------------------------
Name | DR. MICHELLE J MIKUS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 724-414-1425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------