Provider Demographics
NPI:1043381825
Name:MADISON APOTHECARY INC.
Entity Type:Organization
Organization Name:MADISON APOTHECARY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:812-265-4621
Mailing Address - Street 1:835 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-3131
Mailing Address - Country:US
Mailing Address - Phone:812-265-4621
Mailing Address - Fax:812-273-6666
Practice Address - Street 1:835 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3131
Practice Address - Country:US
Practice Address - Phone:812-265-4621
Practice Address - Fax:812-273-6666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006043A332B00000X, 332BX2000X, 3336C0003X
KYIN12463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200847540AMedicaid
IN5851120001Medicare ID - Type Unspecified