Provider Demographics
NPI:1154367423
Name:OXYGEN STORE INC
Entity type:Organization
Organization Name:OXYGEN STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ROMONA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-947-9502
Mailing Address - Street 1:14 NORTH CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338
Mailing Address - Country:US
Mailing Address - Phone:419-947-9502
Mailing Address - Fax:419-947-9902
Practice Address - Street 1:14 NORTH CHERRY STREET
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338
Practice Address - Country:US
Practice Address - Phone:419-947-9502
Practice Address - Fax:419-947-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH59-009271332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2425174Medicaid
OH000000309733OtherANTHEM BC/BS
OH=========002OtherMEDICAL MUTUAL OF OHIO
OH=========002OtherMEDICAL MUTUAL OF OHIO