Healthcare Provider Details

I. General information

NPI: 1689269219
Provider Name (Legal Business Name): SAMANTHA JO DIVINE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S LIBERTY DR
BLOOMINGTON IN
47403-1924
US

IV. Provider business mailing address

500 S LIBERTY DR
BLOOMINGTON IN
47403-1924
US

V. Phone/Fax

Practice location:
  • Phone: 812-349-1392
  • Fax: 812-349-1393
Mailing address:
  • Phone: 812-349-1392
  • Fax: 812-349-1393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26029142A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: