=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295877694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOOSIER PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 07/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3833 HOHMAN AVE.
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46327-1160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-931-7070
-----------------------------------------------------
Fax | 219-931-1235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3833 HOHMAN AVE.
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46327-1160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-931-7070
-----------------------------------------------------
Fax | 219-931-1235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST
-----------------------------------------------------
Name | MR. EDWARD G VISCHAK
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 219-931-7070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 60000203A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------