Provider Demographics
NPI:1033203310
Name:INDIAN RIVER VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:INDIAN RIVER VILLAGE PHARMACY INC
Other - Org Name:INDIAN RIVER VILLAGE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-238-8911
Mailing Address - Street 1:PO BOX 2039
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-2039
Mailing Address - Country:US
Mailing Address - Phone:231-238-8911
Mailing Address - Fax:231-238-9190
Practice Address - Street 1:6433 BARBARA ST
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-9010
Practice Address - Country:US
Practice Address - Phone:231-238-8911
Practice Address - Fax:231-238-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010033943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042171OtherPK
MI2534918Medicaid