Provider Demographics
NPI:1235384827
Name:MARWOOD LOW COST PHARMACY
Entity Type:Organization
Organization Name:MARWOOD LOW COST PHARMACY
Other - Org Name:MARWOOD LOW COST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:METHQAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABU-MAHFOUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-590-1271
Mailing Address - Street 1:3381 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-2305
Mailing Address - Country:US
Mailing Address - Phone:317-246-6700
Mailing Address - Fax:
Practice Address - Street 1:3381 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-2305
Practice Address - Country:US
Practice Address - Phone:317-246-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARWOOD LOW COST PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-24
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336S0011X
IN60006189A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200932340AMedicaid
1562582OtherNCPDP PROVIDER IDENTIFICATION NUMBER