Healthcare Provider Details

I. General information

NPI: 1306210943
Provider Name (Legal Business Name): B&B HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 N COLISEUM BLVD
FORT WAYNE IN
46805-5526
US

IV. Provider business mailing address

1326 N COLISEUM BLVD
FORT WAYNE IN
46805-5526
US

V. Phone/Fax

Practice location:
  • Phone: 260-739-6069
  • Fax: 260-739-6696
Mailing address:
  • Phone: 260-739-6069
  • Fax: 260-739-6696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006518A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRYAN MERIWETHER
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 260-633-8333