Provider Demographics
NPI:1609204767
Name:PROMEDICA PHARMACY GROUP LLC
Entity type:Organization
Organization Name:PROMEDICA PHARMACY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:COEHRS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD RPH
Authorized Official - Phone:419-291-4496
Mailing Address - Street 1:3142 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2920
Mailing Address - Country:US
Mailing Address - Phone:419-291-4496
Mailing Address - Fax:419-214-4350
Practice Address - Street 1:3142 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2920
Practice Address - Country:US
Practice Address - Phone:419-291-4496
Practice Address - Fax:419-214-4350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROMEDICA CONTINUUM SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-28
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0223543503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103343Medicaid
3681586OtherNCPDP