Provider Demographics
NPI:1134130743
Name:MISHAWAKA MEDICAL ARTS PHARMACY
Entity Type:Organization
Organization Name:MISHAWAKA MEDICAL ARTS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH CEO
Authorized Official - Phone:574-255-3331
Mailing Address - Street 1:303 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2189
Mailing Address - Country:US
Mailing Address - Phone:574-255-3331
Mailing Address - Fax:574-255-3331
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2189
Practice Address - Country:US
Practice Address - Phone:574-255-3331
Practice Address - Fax:574-255-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60002411A183500000X
IN26091645A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100301070AMedicaid
IN100301070AMedicaid