Healthcare Provider Details

I. General information

NPI: 1104931138
Provider Name (Legal Business Name): FAIRMOUNT PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N MAIN ST
FAIRMOUNT IN
46928-1654
US

IV. Provider business mailing address

610 E ROMIE LN
SALINAS CA
93901-4209
US

V. Phone/Fax

Practice location:
  • Phone: 765-948-4111
  • Fax: 765-948-4226
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number60005862A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY CRUMP
Title or Position: PRESIDENT
Credential:
Phone: 831-758-0976