Basic Information
| Provider Information | |||||||||
| NPI: | 1871596460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PMC OHIO, LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24165 DETROIT ROAD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406177646 | ||||||||
| FaxNumber: | 4406171815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANERIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5026277000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1275566853 | 05 | MI | MEDICAID | 1007739010023 | 05 | PA | MEDICAID | 0895536 | 05 | OH | MEDICAID |