=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053911503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REX ALAN THORNE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2020
-----------------------------------------------------
Last Update Date | 10/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5720 CHEROKEE CT
-----------------------------------------------------
City | BARGERSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46106-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-401-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5720 CHEROKEE CT
-----------------------------------------------------
City | BARGERSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46106-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-401-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26012714A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------