Provider Demographics
NPI:1083038368
Name:OHIO STATE UNIVERSITY OUTPATIENT PHARMACY
Entity type:Organization
Organization Name:OHIO STATE UNIVERSITY OUTPATIENT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:SCD, FACHE
Authorized Official - Phone:614-293-9806
Mailing Address - Street 1:410 W 10TH AVE
Mailing Address - Street 2:110 DOAN HALL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 ACKERMAN RD
Practice Address - Street 2:SUITE E1014
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-4500
Practice Address - Country:US
Practice Address - Phone:614-293-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03331027-33336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
7358610001Medicare NSC