Healthcare Provider Details

I. General information

NPI: 1962870295
Provider Name (Legal Business Name): PCA CORRECTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 WILLIAMSBURG DR STE A
JEFFERSONVILLE IN
47130-8066
US

IV. Provider business mailing address

1740 WILLIAMSBURG DR STE A
JEFFERSONVILLE IN
47130-8066
US

V. Phone/Fax

Practice location:
  • Phone: 502-964-5359
  • Fax:
Mailing address:
  • Phone: 502-964-5359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number60006494A
License Number StateIN

VIII. Authorized Official

Name: MICHAEL BLACKETER
Title or Position: MANAGING PHARMACIST
Credential:
Phone: 502-608-9183