Basic Information
Provider Information | |||||||||
NPI: | 1881781086 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ESKENAZI HEALTH PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 720 ESKENAZI AVENUE | ||||||||
Address2: | FIFTH THIRD BANK BUILDING, 5TH FLOOR | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462025166 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178803999 | ||||||||
FaxNumber: | 3178800343 | ||||||||
Practice Location | |||||||||
Address1: | 1700 N ILLINOIS ST | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 46202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179415002 | ||||||||
FaxNumber: | 3179415024 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2006 | ||||||||
LastUpdateDate: | 11/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COX | ||||||||
AuthorizedOfficialFirstName: | TODD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MGR OUTPATIENT PHY | ||||||||
AuthorizedOfficialTelephone: | 3178804340 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0002X | 60003811A | IN | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 200152600A | 05 | IN |   | MEDICAID | 2024006 | 01 |   | PK | OTHER |