MEDICARE: CHURCH SQUARE PHARMACY 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	022004150	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	2122864	OTHER		PK

General Provider Information

NPI Number	:	1326376310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHURCH SQUARE PHARMACY INC.

Provider Business Mailing Address
First Line	:	14529 PURITAS AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-2813
Country	:	US
Telephone Number	:	216-651-8685
Fax Number	:	216-651-8766

Provider Business Practice Location Address
First Line	:	3107 CLARK AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-1145
Country	:	US
Telephone Number	:	216-651-8685
Fax Number	:	216-651-8766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ABDEL ABUKHALIL
Credential	:
Telephone Number	:	216-288-0557

Provider Enumeration Date	:	12/02/2009
Last Update Date	:	05/09/2025

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