Provider Demographics
NPI:1891009502
Name:HEALTHSOURCE OF OHIO INC
Entity type:Organization
Organization Name:HEALTHSOURCE OF OHIO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:PRATHER II
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-707-4041
Mailing Address - Street 1:2055 HOSPITAL DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1964
Mailing Address - Country:US
Mailing Address - Phone:513-732-0700
Mailing Address - Fax:513-732-0642
Practice Address - Street 1:2055 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1964
Practice Address - Country:US
Practice Address - Phone:513-732-0700
Practice Address - Fax:513-732-0642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH02-20766503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126485OtherPK
OH3077843Medicaid