Healthcare Provider Details

I. General information

NPI: 1255822409
Provider Name (Legal Business Name): HERBST APOTHECARY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N DIXON RD
KOKOMO IN
46901-4131
US

IV. Provider business mailing address

201 N DIXON RD
KOKOMO IN
46901-4131
US

V. Phone/Fax

Practice location:
  • Phone: 765-457-1191
  • Fax: 765-868-3184
Mailing address:
  • Phone: 765-457-1191
  • Fax: 765-868-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number60002425A
License Number StateIN

VIII. Authorized Official

Name: GREG MILLER
Title or Position: SEC/TRES
Credential:
Phone: 765-457-1191