=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760993026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN WILLIAM SKINNER PHARMD, BCPS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2017
-----------------------------------------------------
Last Update Date | 10/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 W 86TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-338-1456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5771 WATERSTONE WAY
-----------------------------------------------------
City | WHITESTOWN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46075-9001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-512-3905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | 26026069A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------