1376941344 NPI number — SOUTH BEND SPECIALTY PHARMACY LLC

Table of content: (NPI 1376941344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376941344 NPI number — SOUTH BEND SPECIALTY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BEND SPECIALTY 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:
SOUTH BEND SPECIALTY 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:
1376941344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54590 IRONWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-807-6170
Provider Business Mailing Address Fax Number:
877-235-7012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54590 IRONWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46635-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-968-3717
Provider Business Practice Location Address Fax Number:
574-314-6916
Provider Enumeration Date:
12/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ALMEIDA
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
574-968-3717

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 60006503A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2154848 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com