MEDICARE: MEDISERV DUXBERRY PHCY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy
2	3336C0003X	Community/Retail Pharmacy		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3665001	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1104904614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDISERV DUXBERRY PHCY INC

Provider Business Mailing Address
First Line	:	2052 CLEVELAND AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-2216
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2052 CLEVELAND AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-2216
Country	:	US
Telephone Number	:	614-294-0426
Fax Number	:	614-481-4272

Authorized Official
Title or Position	:	THIRD PARTY ADMIN
Name	:	TRACY HAMMOND
Credential	:
Telephone Number	:	614-481-4272

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	09/11/2025

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