Provider Demographics
NPI:1164407441
Name:DOCTOR'S PHARMACY
Entity Type:Organization
Organization Name:DOCTOR'S PHARMACY
Other - Org Name:DOCTOR'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GORTAT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:219-923-2520
Mailing Address - Street 1:2727 HIGHWAY AVE
Mailing Address - Street 2:PHARMACY
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1615
Mailing Address - Country:US
Mailing Address - Phone:219-923-2520
Mailing Address - Fax:219-923-2701
Practice Address - Street 1:2727 HIGHWAY AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1615
Practice Address - Country:US
Practice Address - Phone:219-923-2520
Practice Address - Fax:219-923-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60004131A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100298480AMedicaid
IN100298480AMedicaid