Provider Demographics
NPI:1811058886
Name:XENIA PHARMACY LLC
Entity type:Organization
Organization Name:XENIA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWBRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-376-5556
Mailing Address - Street 1:631 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-3613
Mailing Address - Country:US
Mailing Address - Phone:937-376-5556
Mailing Address - Fax:937-435-5759
Practice Address - Street 1:631 W 2ND ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3613
Practice Address - Country:US
Practice Address - Phone:937-376-5556
Practice Address - Fax:937-435-5759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2303224Medicaid
5021270001Medicare ID - Type Unspecified