# MARYMOUNT HOSPITAL

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- **Entity:** Organization
- **Status:** Active
- **Other names:** MARYMOUNT FAMILY PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811932049
- **Authorized official:** MR. TIM LONGVILLE MHA, RPH (CHIEF ACCOUNTING OFFICER AND CONTRO)
- **Authorized official phone:** (216) 636-7416

## Contact information

- **Practice address:** 12000 MCCRACKEN RD, STE 151, GARFIELD HEIGHTS, OH 44125-2964
- **Practice address phone:** (216) 578-8822
- **Practice address fax:** (216) 587-8844
- **Mailing address:** PO BOX 931783, CLEVELAND, OH 44193-1884
- **Mailing address phone:** (216) 445-2357
- **Mailing address fax:** (216) 445-0025

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0002X | Clinic Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 021567350 | OH | Yes |

## Other

- **Enumeration date:** 06/19/2006
- **Last updated:** 10/11/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 3674101 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |