Healthcare Provider Details

I. General information

NPI: 1811613508
Provider Name (Legal Business Name): THEODORE J LINGENFELTER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 BREMEN HWY
MISHAWAKA IN
46544-6500
US

IV. Provider business mailing address

51618 MEADOW POINTE
GRANGER IN
46530-5125
US

V. Phone/Fax

Practice location:
  • Phone: 574-254-2510
  • Fax: 574-254-2565
Mailing address:
  • Phone: 574-326-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number26029859A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: