Healthcare Provider Details

I. General information

NPI: 1043381825
Provider Name (Legal Business Name): MADISON APOTHECARY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 W MAIN ST
MADISON IN
47250-3131
US

IV. Provider business mailing address

835 W MAIN ST
MADISON IN
47250-3131
US

V. Phone/Fax

Practice location:
  • Phone: 812-265-4621
  • Fax: 812-273-6666
Mailing address:
  • Phone: 812-265-4621
  • Fax: 812-273-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number60006043A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number60006043A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006043A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberIN1246
License Number StateKY

VIII. Authorized Official

Name: DR. ERIK R GROVE
Title or Position: PRESIDENT
Credential: PHARM.D.
Phone: 812-265-4621