Healthcare Provider Details

I. General information

NPI: 1174091557
Provider Name (Legal Business Name): RUBICON DTP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 W 73RD ST # A
INDIANAPOLIS IN
46278-1741
US

IV. Provider business mailing address

5175 W 73RD STREET B
INDIANAPOLIS IN
46278
US

V. Phone/Fax

Practice location:
  • Phone: 317-524-1515
  • Fax: 844-325-7228
Mailing address:
  • Phone: 833-200-2010
  • Fax: 317-552-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID BURAND
Title or Position: PRESIDENT- PIC
Credential: RPH
Phone: 317-552-1100