Provider Demographics
NPI:1235388356
Name:PRAIRESTONE PHARMACY LLC
Entity Type:Organization
Organization Name:PRAIRESTONE PHARMACY LLC
Other - Org Name:DAILYMED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-569-8234
Mailing Address - Street 1:PO BOX 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9830
Mailing Address - Country:US
Mailing Address - Phone:877-540-4748
Mailing Address - Fax:801-716-4872
Practice Address - Street 1:9320 PRIORITY WAY WEST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1468
Practice Address - Country:US
Practice Address - Phone:317-573-0045
Practice Address - Fax:317-573-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IN60006165A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2878186Medicaid
1562378OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH2878186Medicaid