Provider Demographics
NPI:1235851494
Name:INDIGO PHARMACEUTICAL LLC
Entity Type:Organization
Organization Name:INDIGO PHARMACEUTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:702-427-0707
Mailing Address - Street 1:270 S MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4305
Mailing Address - Country:US
Mailing Address - Phone:954-557-0061
Mailing Address - Fax:
Practice Address - Street 1:270 S MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4305
Practice Address - Country:US
Practice Address - Phone:954-557-0061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy