Provider Demographics
NPI:1427489467
Name:WEST JEFFERSON DRUGGIST LLC
Entity type:Organization
Organization Name:WEST JEFFERSON DRUGGIST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:614-573-1557
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-0126
Mailing Address - Country:US
Mailing Address - Phone:614-573-1557
Mailing Address - Fax:614-300-7558
Practice Address - Street 1:487 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-1178
Practice Address - Country:US
Practice Address - Phone:614-879-8500
Practice Address - Fax:614-879-6171
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO APOTHECARIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-02
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OHRTP022385600033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109253Medicaid
2147441OtherPK
H316810Medicare PIN