Healthcare Provider Details

I. General information

NPI: 1164090825
Provider Name (Legal Business Name): BLUE RIVER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 S GREEN ST
BROWNSBURG IN
46112-1251
US

IV. Provider business mailing address

26 S GREEN ST
BROWNSBURG IN
46112-1251
US

V. Phone/Fax

Practice location:
  • Phone: 317-286-3506
  • Fax: 317-350-2917
Mailing address:
  • Phone: 317-286-3506
  • Fax: 317-350-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PAUL CRUZAN
Title or Position: PRESIDENT
Credential:
Phone: 317-286-3506