=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831529288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSCRIPT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 03/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9292 N MERIDIAN ST STE 103
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-700-6001
-----------------------------------------------------
Fax | 866-700-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9292 N MERIDIAN ST STE 103
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-700-6001
-----------------------------------------------------
Fax | 866-700-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ZIAD KHADER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-658-0001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 60006360A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------