Provider Demographics
NPI:1962584763
Name:CLINIC PHARMACY INC
Entity type:Organization
Organization Name:CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-252-4348
Mailing Address - Street 1:1000 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1381
Mailing Address - Country:US
Mailing Address - Phone:614-252-4348
Mailing Address - Fax:614-252-5079
Practice Address - Street 1:1000 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1381
Practice Address - Country:US
Practice Address - Phone:614-252-4348
Practice Address - Fax:614-252-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP020471900033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2075563OtherPK
OH0634559Medicaid
0591720001Medicare NSC