Provider Demographics
NPI:1396805537
Name:IDEAL PHARMACY
Entity type:Organization
Organization Name:IDEAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEGAL COUNCEL
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WENKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-381-9222
Mailing Address - Street 1:1840 DUCK CREEK RD
Mailing Address - Street 2:APT 3
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45207-1625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2916 GILBERT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-1207
Practice Address - Country:US
Practice Address - Phone:513-751-6665
Practice Address - Fax:513-751-2870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
OH333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3133087065601Medicaid
3611375OtherOTHER ID NUMBER-COMMERCIAL NUMBER