Provider Demographics
NPI:1003802927
Name:PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY
Other - Org Name:DEXTER HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FARNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:574-722-5678
Mailing Address - Street 1:800 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1577
Mailing Address - Country:US
Mailing Address - Phone:574-722-5678
Mailing Address - Fax:574-753-5597
Practice Address - Street 1:800 FULTON ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1577
Practice Address - Country:US
Practice Address - Phone:574-722-5678
Practice Address - Fax:574-753-5597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000792A332B00000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100175590Medicaid
1518616OtherNCPDP PROVIDER IDENTIFICATION NUMBER