1083741474 NPI number — THE 3171 MERIDIAN PHARMACY, INC.

Table of content: FORREST SIMPSON WELLS MD (NPI 1477568749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083741474 NPI number — THE 3171 MERIDIAN PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE 3171 MERIDIAN PHARMACY, INC.
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:
MERIDIAN PHARMACY
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:
1083741474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 88247
Provider Second Line Business Mailing Address:
3737 N MERIDIAN ST., #106
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46208-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-283-6908
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3737 N MERIDIAN ST
Provider Second Line Business Practice Location Address:
106
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46208-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-283-6908
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
LAM
Authorized Official Middle Name:
Q
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
317-590-0829

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  60007749 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1531804 . This is a "NAPB #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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