1972794816 NPI number — PLYMOUTH TOWNE CARE PHARMACY INC

Table of content: (NPI 1972794816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972794816 NPI number — PLYMOUTH TOWNE CARE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLYMOUTH TOWNE CARE 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:
6
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:
1972794816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2855 MILLER DR
Provider Second Line Business Mailing Address:
STE 111
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46563-8091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2855 MILLER DR
Provider Second Line Business Practice Location Address:
STE 111
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46563-8091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-941-1067
Provider Business Practice Location Address Fax Number:
574-941-1076
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ORENDOR
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-930-3167

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  60006058A , 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: 1561782 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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