Provider Demographics
NPI:1043683568
Name:VILLAGE APOTHECARY AT WILLIAMSBURG
Entity Type:Organization
Organization Name:VILLAGE APOTHECARY AT WILLIAMSBURG
Other - Org Name:VILLAGE APOTHECARY AT WILLIAMSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRICEK
Authorized Official - Suffix:
Authorized Official - Credentials:BSPH
Authorized Official - Phone:765-364-0363
Mailing Address - Street 1:1609 LAFAYETTE RD RM 23
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1032
Mailing Address - Country:US
Mailing Address - Phone:765-364-0363
Mailing Address - Fax:765-362-2436
Practice Address - Street 1:1609 LAFAYETTE RD RM 23
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1032
Practice Address - Country:US
Practice Address - Phone:765-364-0363
Practice Address - Fax:765-362-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BN1400X, 332BX2000X, 333600000X
IN60006523A3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201348390AMedicaid
2155103OtherPK