=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326777483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUMINATE HEALTH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 06/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12400 N MERIDIAN ST STE 150
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-6990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-605-2390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12400 N MERIDIAN ST STE 150
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-6990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-605-2390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | DR. STEPHANIE MAE GAHIMER HYSLOP
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 317-512-5459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------