MEDICARE: BEACON HEALTH VENTURES INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336H0001X	Home Infusion Therapy Pharmacy

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	M300042869	OTHER	IN	MEDICARE PART B/IMMUNIZATIONS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	100263690A	OTHER	IN	WAIVER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	000000097412	OTHER	IN	ANTHEM PROVIDER
5	000000107793	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1790859403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACON HEALTH VENTURES INC

Provider Business Mailing Address
First Line	:	3355 DOUGLAS RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1779
Country	:	US
Telephone Number	:	574-647-8675
Fax Number	:	574-647-8764

Provider Business Practice Location Address
First Line	:	3355 DOUGLAS RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1779
Country	:	US
Telephone Number	:	574-647-8675
Fax Number	:	574-647-8764

Authorized Official
Title or Position	:	MANAGER
Name	:	TRUDY K WAIT
Credential	:
Telephone Number	:	574-647-8674

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	12/09/2025

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Directions to “BEACON HEALTH VENTURES INC ” Practice Location

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