=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386152783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI STATE UROLOGIC SERVICES PSC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2018
-----------------------------------------------------
Last Update Date | 01/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 JOSEPH E SANKER BLVD STE 210 SUITE 210
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-841-7492
-----------------------------------------------------
Fax | 513-841-7401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 JOSEPH E SANKER BLVD STE 210 SUITE 210
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-841-7492
-----------------------------------------------------
Fax | 513-841-7401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MELISSA RUTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-841-7492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PMY.022816250-0
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------