=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700669371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S HOSPITAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2023
-----------------------------------------------------
Last Update Date | 08/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5642 HAMILTON AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45224-3114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-636-0996
-----------------------------------------------------
Fax | 513-636-0995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3333 BURNET AVE # MLC1011
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45229-3026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-636-8808
-----------------------------------------------------
Fax | 513-636-5876
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ANALYST II / APPL
-----------------------------------------------------
Name | BILL TACKETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-636-8175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------