Healthcare Provider Details

I. General information

NPI: 1558088864
Provider Name (Legal Business Name): VADIM ZHURAVENKO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 APPLE GLEN BLVD
FORT WAYNE IN
46804-1725
US

IV. Provider business mailing address

15030 JASMINE KEY CT
FORT WAYNE IN
46814-8975
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-0113
  • Fax:
Mailing address:
  • Phone: 224-305-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026838A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: