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General NPI Number Information
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NPI Number | 1497805717
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Entity Type | Organization
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Legal Business Name | VILLAGE DRUG STORE
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 10/26/2011
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Provider Practice Location Address
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Address Line | 1313 HOMEWOOD DR
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City | CRAWFORDSVILLE
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State | IN
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Zip | 47933-3341
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Country | US
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Telephone | 765-364-0324
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Fax | 765-364-0325
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Provider Business Mailing Address
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Address Line | PO BOX 661
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City | CRAWFORDSVILLE
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State | IN
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Zip | 47933-0661
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Country | US
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Telephone | 765-364-0324
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Fax | 765-364-0325
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Authorized Official
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Title or Position | MANAGER
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Name | JOSEPH FRANK PETRICEK
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Credential | RPH
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Telephone | 765-364-0324
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 60002857A
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License Number State | IN
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