Provider Demographics
NPI:1528088119
Name:SCHWIETERMANS DRUG STORE INC
Entity type:Organization
Organization Name:SCHWIETERMANS DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-629-2336
Mailing Address - Street 1:324 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MINSTER
Mailing Address - State:OH
Mailing Address - Zip Code:45865-9560
Mailing Address - Country:US
Mailing Address - Phone:419-628-2305
Mailing Address - Fax:419-628-2119
Practice Address - Street 1:324 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865-9560
Practice Address - Country:US
Practice Address - Phone:419-628-2305
Practice Address - Fax:419-628-2119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH025980003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0847203Medicaid
2072067OtherPK
0311170002Medicare NSC