MEDICARE: IHS PHARMACY & WELLNESS CENTER

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	3336C0003X	Community/Retail Pharmacy	022075950	OH

General Provider Information

NPI Number	:	1508174350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IHS PHARMACY & WELLNESS CENTER

Provider Business Mailing Address
First Line	:	4940 COTTONVILLE RD
Second Line	:
City	:	JAMESTOWN
State	:	OH
Zip	:	45335-1522
Country	:	US
Telephone Number	:	937-675-6500
Fax Number	:	937-675-6540

Provider Business Practice Location Address
First Line	:	4940 COTTONVILLE RD
Second Line	:
City	:	JAMESTOWN
State	:	OH
Zip	:	45335-1522
Country	:	US
Telephone Number	:	937-675-6500
Fax Number	:	937-675-6540

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MR. TODD ALLEN TACKAGE
Credential	:
Telephone Number	:	740-572-1561

Provider Enumeration Date	:	09/15/2010
Last Update Date	:	09/28/2010

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