Provider Demographics
NPI:1134128705
Name:ELKHART GENERAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:ELKHART GENERAL HOSPITAL, INC.
Other - Org Name:ELKHART GENERAL OUT PATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3460
Mailing Address - Street 1:600 EAST BLVD
Mailing Address - Street 2:O/P PHARMACY
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514
Mailing Address - Country:US
Mailing Address - Phone:574-523-3549
Mailing Address - Fax:574-523-7802
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:O/P PHARMACY
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514
Practice Address - Country:US
Practice Address - Phone:574-523-3549
Practice Address - Fax:574-523-7802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELKHART GENERAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-18
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60004113A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100295480AMedicaid
IN0833040001Medicare NSC