MEDICARE: RANDY W IVANOV PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26023680A	IN

General Provider Information

NPI Number	:	1508149188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDY W IVANOV PHARM.D.

Provider Business Mailing Address
First Line	:	3205 E WASHINGTON ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46201-4207
Country	:	US
Telephone Number	:	317-681-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	3205 E WASHINGTON ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46201-4207
Country	:	US
Telephone Number	:	317-681-1111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	09/21/2011

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