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General NPI Number Information
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NPI Number | 1487016796
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Entity Type | Organization
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Legal Business Name | KETTERING MEDICAL CENTER
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Dates
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Enumeration Date | 03/25/2016
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Last Update Date | 02/28/2017
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Provider Practice Location Address
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Address Line | 825 N MAIN ST
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City | SPRINGBORO
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State | OH
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Zip | 45066-2100
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Country | US
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Telephone | 937-762-5090
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Fax | 937-762-5091
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Provider Business Mailing Address
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Address Line | 825 N MAIN ST
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City | SPRINGBORO
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State | OH
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Zip | 45066-2100
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Country | US
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Telephone | 937-762-5090
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Fax | 937-522-7198
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Authorized Official
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Title or Position | DIRECTOR OF PHARMACY
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Name | KEVIN BLACKBURN
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Credential | RPH
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Telephone | 937-458-4932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PMY.022604450-03
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License Number State | OH
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