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General NPI Number Information
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NPI Number | 1033203310
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Entity Type | Organization
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Legal Business Name | INDIAN RIVER VILLAGE PHARMACY INC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/05/2016
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Provider Practice Location Address
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Address Line | 6433 BARBARA ST
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City | INDIAN RIVER
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State | MI
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Zip | 49749-9010
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Country | US
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Telephone | 231-238-8911
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Fax | 231-238-9190
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Provider Business Mailing Address
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Address Line | PO BOX 2039
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City | INDIAN RIVER
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State | MI
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Zip | 49749-2039
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Country | US
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Telephone | 231-238-8911
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Fax | 231-238-9190
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Authorized Official
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Title or Position | PRESIDENT
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Name | THOMAS BAHRA
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Credential |
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Telephone | 231-238-8911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301003394
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License Number State | MI
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