Provider Demographics
NPI:1053727545
Name:CHURCH SQUARE PHARMACY
Entity type:Organization
Organization Name:CHURCH SQUARE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUKHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-288-0557
Mailing Address - Street 1:14529 PURITAS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-2813
Mailing Address - Country:US
Mailing Address - Phone:216-476-1400
Mailing Address - Fax:216-476-1401
Practice Address - Street 1:14529 PURITAS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-2813
Practice Address - Country:US
Practice Address - Phone:216-476-1400
Practice Address - Fax:216-476-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
OHRTP022427600033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2145685Medicaid
2145685OtherPK