=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588318406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARNESS HEALTH PHARMACY - OHIO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12623 ECKEL JUNCTION RD
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-358-1434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12623 ECKEL JUNCTION RD
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SYSTEM DIRECTOR
-----------------------------------------------------
Name | KIMBERLY RALSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-996-5119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------