Healthcare Provider Details

I. General information

NPI: 1386480408
Provider Name (Legal Business Name): ASHANTA DOMONIQUE COLEMEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E COUNTY LINE RD STE B
GREENWOOD IN
46143-1080
US

IV. Provider business mailing address

11039 BEAR HOLLOW DR
INDIANAPOLIS IN
46229-3119
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-7333
  • Fax:
Mailing address:
  • Phone: 317-374-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number26030402A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: