Healthcare Provider Details

I. General information

NPI: 1134130743
Provider Name (Legal Business Name): MISHAWAKA MEDICAL ARTS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S MAIN ST
MISHAWAKA IN
46544-2189
US

IV. Provider business mailing address

303 S MAIN ST
MISHAWAKA IN
46544-2189
US

V. Phone/Fax

Practice location:
  • Phone: 574-255-3331
  • Fax: 574-255-3331
Mailing address:
  • Phone: 574-255-3331
  • Fax: 574-255-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26091645A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60002411A
License Number StateIN

VIII. Authorized Official

Name: MR. ALVIN E JONES
Title or Position: PHARMACIST OWNER
Credential: RPH CEO
Phone: 574-255-3331