Provider Demographics
NPI:1386059228
Name:SOUTHERN OHIO MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN OHIO MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:RORY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-356-8193
Mailing Address - Street 1:90 CIC BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-8024
Mailing Address - Country:US
Mailing Address - Phone:937-544-8989
Mailing Address - Fax:937-544-5839
Practice Address - Street 1:90 CIC BLVD
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-8024
Practice Address - Country:US
Practice Address - Phone:937-544-8989
Practice Address - Fax:937-544-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP022424300033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146607OtherPK
OH0108488Medicaid
7240560001Medicare NSC