Provider Demographics
NPI:1194484493
Name:PERRY PHARMACY ENTERPRISE LLC
Entity type:Organization
Organization Name:PERRY PHARMACY ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:937-452-1263
Mailing Address - Street 1:75 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:OH
Mailing Address - Zip Code:45311-1007
Mailing Address - Country:US
Mailing Address - Phone:937-452-1263
Mailing Address - Fax:937-452-3957
Practice Address - Street 1:75 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:OH
Practice Address - Zip Code:45311-1007
Practice Address - Country:US
Practice Address - Phone:937-452-1263
Practice Address - Fax:937-452-3957
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAMDEN VILLAGE PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-14
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0009702Medicaid
OH0492926Medicaid