Healthcare Provider Details

I. General information

NPI: 1043683568
Provider Name (Legal Business Name): VILLAGE APOTHECARY AT WILLIAMSBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 LAFAYETTE RD RM 23
CRAWFORDSVILLE IN
47933-1032
US

IV. Provider business mailing address

1609 LAFAYETTE RD RM 23
CRAWFORDSVILLE IN
47933-1032
US

V. Phone/Fax

Practice location:
  • Phone: 765-364-0363
  • Fax: 765-362-2436
Mailing address:
  • Phone: 765-364-0363
  • Fax: 765-362-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number60006523A
License Number StateIN

VIII. Authorized Official

Name: JOSEPH PETRICEK
Title or Position: PHARMACIST IN CHARGE
Credential: BSPH
Phone: 765-364-0363