=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164407441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOCTOR'S PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2005
-----------------------------------------------------
Last Update Date | 01/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2727 HIGHWAY AVE PHARMACY
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46322-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-923-2520
-----------------------------------------------------
Fax | 219-923-2701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2727 HIGHWAY AVE PHARMACY
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46322-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-923-2520
-----------------------------------------------------
Fax | 219-923-2701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/TREASURER
-----------------------------------------------------
Name | MR. DAVID LEE GORTAT
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 219-923-2520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 60004131A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------