Provider Demographics
NPI:1366562852
Name:INDEPENDENT PHARMACY GROUP INC
Entity type:Organization
Organization Name:INDEPENDENT PHARMACY GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PETRACCI
Authorized Official - Suffix:
Authorized Official - Credentials:REG PHARM
Authorized Official - Phone:330-746-2657
Mailing Address - Street 1:602 PARMALEE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1653
Mailing Address - Country:US
Mailing Address - Phone:330-746-2657
Mailing Address - Fax:330-746-0014
Practice Address - Street 1:602 PARMALEE AVE
Practice Address - Street 2:STE 100
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1653
Practice Address - Country:US
Practice Address - Phone:330-746-2657
Practice Address - Fax:330-746-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0952992Medicaid
3643764OtherOTHER ID NUMBER
3643764OtherOTHER ID NUMBER