Provider Demographics
NPI:1154676476
Name:GUARDIAN PHARMACY OF INDIANAPOLIS LTC, LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF INDIANAPOLIS LTC, LLC
Other - Org Name:GUARDIAN PHARMACY OF INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIEPENBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-320-4669
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT # 2421
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2421
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:6530 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2915
Practice Address - Country:US
Practice Address - Phone:317-452-4669
Practice Address - Fax:866-320-4744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60006311A3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136626OtherPK
IN201081960AMedicaid