1770524472 NPI number — WILLIAMS LTC PHARMACY, LLC

Table of content: (NPI 1770524472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770524472 NPI number — WILLIAMS LTC PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAMS LTC PHARMACY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILLIAMS LTC PHARMACY, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770524472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 498
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47501-0498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-254-2497
Provider Business Mailing Address Fax Number:
812-257-2592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11900 EXIT 5 PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46037-7939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-889-4125
Provider Business Practice Location Address Fax Number:
317-889-4134
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
CLAYBORNE
Authorized Official Title or Position:
OWNER/CHIEF STRATEGY OFFICER
Authorized Official Telephone Number:
812-254-2497

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  60006345A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 203.001778 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 60006345A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 203.001778 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 60006345A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 054.018509 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: NRP.022594950-03 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 054.018509 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 60006345A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X , with the licence number: NRP.022594950-03 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200446060A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2142039 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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