Provider Demographics
NPI:1306960513
Name:MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-334-6618
Mailing Address - Street 1:715 S TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3237
Mailing Address - Country:US
Mailing Address - Phone:419-334-6618
Mailing Address - Fax:419-334-6678
Practice Address - Street 1:715 S TAFT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3237
Practice Address - Country:US
Practice Address - Phone:419-334-6618
Practice Address - Fax:419-334-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHOS.020030100-033336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2075169OtherPK