Organization
APOTHEKE INC
Active
Other names
THE VINTAGE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY ICKES RPH (OWNER)
(440) 963-7760
Entity
Organization
Contact information
Practice address
1605 STATE ROUTE 60, SUITE 11, VERMILION, OH 44089
(440) 967-3100
(440) 967-3110
Mailing address
1605 STATE ROUTE 60, SUITE 11, VERMILION, OH 44089
(440) 967-3100
(440) 967-3110
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
021800200
OH
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0624677
—
OH
01
—
3644956
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
09/14/2006
Last updated
10/05/2011
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