Provider Demographics
NPI:1396243069
Name:AGS HOLDING LLC
Entity type:Organization
Organization Name:AGS HOLDING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,RPH,AO
Authorized Official - Prefix:
Authorized Official - First Name:LAP PAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-287-7088
Mailing Address - Street 1:209 BIERLEY AVE
Mailing Address - Street 2:PO BOX 839
Mailing Address - City:PEMBERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43450-7003
Mailing Address - Country:US
Mailing Address - Phone:419-287-7088
Mailing Address - Fax:419-287-7091
Practice Address - Street 1:209 BIERLEY AVE
Practice Address - Street 2:
Practice Address - City:PEMBERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43450-7003
Practice Address - Country:US
Practice Address - Phone:419-287-7088
Practice Address - Fax:419-287-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHPMY.022861200-03336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176668OtherPK