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General NPI Number Information
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NPI Number | 1689743320
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Entity Type | Organization
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Legal Business Name | YOURX STORE INC
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 01/25/2011
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Provider Practice Location Address
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Address Line | 27 S MAIN STREET
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City | MARENGO
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State | OH
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Zip | 43334
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Country | US
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Telephone | 419-253-3831
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 47
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City | MARENGO
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State | OH
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Zip | 43334-0047
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Country | US
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Telephone | 419-253-3831
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LARRY HILDEBRAND
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Credential |
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Telephone | 419-253-3831
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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 | 020086300
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License Number State | OH
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