Healthcare Provider Details

I. General information

NPI: 1336457555
Provider Name (Legal Business Name): CHARLES KENT STEMBEL ESTATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S GRANT AVE
FOWLER IN
47944-1636
US

IV. Provider business mailing address

500 S GRANT AVE
FOWLER IN
47944-1636
US

V. Phone/Fax

Practice location:
  • Phone: 765-884-1520
  • Fax: 765-884-8329
Mailing address:
  • Phone: 765-884-1520
  • Fax: 765-884-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number26015054A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number26015054A
License Number StateIN

VIII. Authorized Official

Name: SHARI STEMBEL
Title or Position: ESTATE ADMINISTRATOR
Credential:
Phone: 765-884-1520