Healthcare Provider Details

I. General information

NPI: 1003802927
Provider Name (Legal Business Name): PROFESSIONAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FULTON ST
LOGANSPORT IN
46947-1577
US

IV. Provider business mailing address

800 FULTON ST
LOGANSPORT IN
46947-1577
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-5678
  • Fax: 574-753-5597
Mailing address:
  • Phone: 574-722-5678
  • Fax: 574-753-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number69000792A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE FARNHAM
Title or Position: CORP SECRETARY TREASURER
Credential: RPH
Phone: 574-722-5678