Provider Demographics
NPI:1083494348
Name:GG II INDIANA, LLC
Entity Type:Organization
Organization Name:GG II INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:317-450-5335
Mailing Address - Street 1:3015 W US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-9280
Mailing Address - Country:US
Mailing Address - Phone:765-221-7100
Mailing Address - Fax:
Practice Address - Street 1:3015 W US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9280
Practice Address - Country:US
Practice Address - Phone:765-221-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy