Provider Demographics
NPI:1164090825
Name:BLUE RIVER PHARMACY INC
Entity Type:Organization
Organization Name:BLUE RIVER PHARMACY INC
Other - Org Name:BLUE RIVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-286-3506
Mailing Address - Street 1:26 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-1251
Mailing Address - Country:US
Mailing Address - Phone:317-286-3506
Mailing Address - Fax:317-350-2917
Practice Address - Street 1:26 S GREEN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1251
Practice Address - Country:US
Practice Address - Phone:317-286-3506
Practice Address - Fax:317-350-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200914920AMedicaid