# PEMBERVILLE DRUG STORE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1184907115
- **Authorized official:** MR. JOSEPH LEE BAUMGARTNER RPH (OWNER)
- **Authorized official phone:** (419) 287-3238

## Contact information

- **Practice address:** 139 E FRONT ST \# 897, PEMBERVILLE, OH 43450-7032
- **Practice address phone:** (419) 287-3238
- **Practice address fax:** (419) 287-2008
- **Mailing address:** 139 E FRONT ST \# 897, PEMBERVILLE, OH 43450-7032
- **Mailing address phone:** (419) 287-3238
- **Mailing address fax:** (419) 287-2008

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336L0003X | Long Term Care Pharmacy | 022122100 | OH | Yes |

## Other

- **Enumeration date:** 09/26/2011
- **Last updated:** 09/26/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 2010620 | — | OH |