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General NPI Number Information
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NPI Number | 1972886687
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Entity Type | Individual
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Provider Name | PHILIPPE AA PELLERIN JR.
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Gender | Male
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Dates
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Enumeration Date | 09/20/2011
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Last Update Date | 09/20/2011
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Provider Practice Location Address
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Address Line | 330 W STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46808-3135
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Country | US
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Telephone | 260-482-5428
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Fax | 260-484-6355
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Provider Business Mailing Address
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Address Line | 330 W STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46808-3135
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Country | US
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Telephone | 260-482-5428
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Fax | 260-484-6355
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 26015598A
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License Number State | IN
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