Provider Demographics
NPI:1245306901
Name:SUGARCREEK PLAZA FOODS LLC
Entity type:Organization
Organization Name:SUGARCREEK PLAZA FOODS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFINO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-431-1662
Mailing Address - Street 1:6134 WASHINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:937-848-4600
Mailing Address - Fax:937-848-3666
Practice Address - Street 1:6134 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-7029
Practice Address - Country:US
Practice Address - Phone:937-848-6691
Practice Address - Fax:937-848-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
OHRTP0209408503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3662461OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0287194Medicaid
3662461OtherNCPDP PROVIDER IDENTIFICATION NUMBER