Healthcare Provider Details

I. General information

NPI: 1861077521
Provider Name (Legal Business Name): CHARITY CICAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

IV. Provider business mailing address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-4525
  • Fax:
Mailing address:
  • Phone: 317-501-8954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026898A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: