Healthcare Provider Details

I. General information

NPI: 1265823926
Provider Name (Legal Business Name): PANACEA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 S WALNUT ST
BLOOMINGTON IN
47401-7730
US

IV. Provider business mailing address

PO BOX 366
BEDFORD IN
47421-0366
US

V. Phone/Fax

Practice location:
  • Phone: 812-287-8884
  • Fax: 812-287-8921
Mailing address:
  • Phone: 812-276-5782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006429A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA ANDERSON
Title or Position: PRESIDENT
Credential:
Phone: 812-276-5782