MEDICARE: PLYMOUTH TOWNE CARE PHARMACY INC

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	3336C0003X	Community/Retail Pharmacy	60006058A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1561782	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1972794816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLYMOUTH TOWNE CARE PHARMACY INC

Provider Business Mailing Address
First Line	:	2855 MILLER DR
Second Line	:	STE 111
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-8091
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2855 MILLER DR
Second Line	:	STE 111
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-8091
Country	:	US
Telephone Number	:	574-941-1067
Fax Number	:	574-941-1076

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES ORENDOR
Credential	:
Telephone Number	:	574-930-3167

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	09/13/2007

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