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General NPI Number Information
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NPI Number | 1174187553
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Entity Type | Organization
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Legal Business Name | THE SOUTH BEND CLINIC LLC
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Dates
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Enumeration Date | 05/01/2019
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 52500 FIR RD
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City | GRANGER
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State | IN
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Zip | 46530-8579
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Country | US
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Telephone | 574-204-7260
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Fax |
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Provider Business Mailing Address
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Address Line | 211 N EDDY ST
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City | SOUTH BEND
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State | IN
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Zip | 46617-3096
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Country | US
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Telephone | 574-237-9295
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Fax | 574-239-1554
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Authorized Official
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Title or Position | EXEC DIRECTORY OF PHARMACY
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Name | ANDREA KRUPA
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Credential |
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Telephone | 574-239-1461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number |
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License Number State |
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