Provider Demographics
NPI:1871788265
Name:MAPLE LEAF GROUP
Entity type:Organization
Organization Name:MAPLE LEAF GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:JERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:614-272-6791
Mailing Address - Street 1:PO BOX 27005
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-0005
Mailing Address - Country:US
Mailing Address - Phone:614-274-5890
Mailing Address - Fax:614-443-1020
Practice Address - Street 1:2575 W BROAD ST STE 5
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3333
Practice Address - Country:US
Practice Address - Phone:614-274-5890
Practice Address - Fax:614-274-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHPMY.021746200-033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2772629Medicaid
2081077OtherPK