1053314021 NPI number — GEORGE'S FAMILY PHARMACY INC

Table of content: (NPI 1053314021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053314021 NPI number — GEORGE'S FAMILY PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE'S FAMILY 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:
Provider Other Organization Name Type Code:
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:
1053314021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47012-1406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-647-6251
Provider Business Mailing Address Fax Number:
765-647-6386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47012-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-647-6251
Provider Business Practice Location Address Fax Number:
765-647-6386
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GILLMAN
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
765-647-6251

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  60003113A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 60003113A , 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: 1509794 . This is a "NABP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2167971 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000097297 . This is a "ANTHEM PROV ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100295890A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00110488 . This is a "RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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