Basic Information
| Provider Information | |||||||||
| NPI: | 1912091679 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTSIDE COMMUNITY HEALTH CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 2732 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175544638 | ||||||||
| FaxNumber: | 3175544660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OUTPATIENT PHCY | ||||||||
| AuthorizedOfficialTelephone: | 3178804340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0002X | 60004904A | IN | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2028277 | 01 | PK | OTHER | 200152610A | 05 | IN | MEDICAID |