Healthcare Provider Details

I. General information

NPI: 1144583014
Provider Name (Legal Business Name): LORA ERTMOED PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2012
Last Update Date: 06/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 N MERIDIAN ST SUITE 100A
INDIANAPOLIS IN
46202-1468
US

IV. Provider business mailing address

1776 N MERIDIAN ST SUITE 100A
INDIANAPOLIS IN
46202-1468
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-1746
  • Fax: 317-962-4070
Mailing address:
  • Phone: 317-962-1746
  • Fax: 317-962-4070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26022736A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: