Healthcare Provider Details

I. General information

NPI: 1235388356
Provider Name (Legal Business Name): PRAIRESTONE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 PRIORITY WAY WEST DR
INDIANAPOLIS IN
46240-1468
US

IV. Provider business mailing address

PO BOX 9830
SALT LAKE CITY UT
84109-9830
US

V. Phone/Fax

Practice location:
  • Phone: 317-573-0045
  • Fax: 317-573-0206
Mailing address:
  • Phone: 877-540-4748
  • Fax: 801-716-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006165A
License Number StateIN

VIII. Authorized Official

Name: MATT MIDDENDORF
Title or Position: CHIEF FINANCIAL OFFICE
Credential:
Phone: 317-569-8234