=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770681827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUND DRUG CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 09/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 S. FRONT ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-332-5585
-----------------------------------------------------
Fax | 419-332-4999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 S. FRONT ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-332-5585
-----------------------------------------------------
Fax | 419-332-4999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT TREASURER PHARMACIST
-----------------------------------------------------
Name | VINCENT MILITELLO
-----------------------------------------------------
Credential | R PH
-----------------------------------------------------
Telephone | 419-332-5585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 02-0146200
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------