Provider Demographics
NPI:1265823926
Name:PANACEA PHARMACY INC
Entity Type:Organization
Organization Name:PANACEA PHARMACY INC
Other - Org Name:PANACEA PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-276-5782
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-0366
Mailing Address - Country:US
Mailing Address - Phone:812-276-5782
Mailing Address - Fax:
Practice Address - Street 1:2424 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7730
Practice Address - Country:US
Practice Address - Phone:812-287-8884
Practice Address - Fax:812-287-8921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-16
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006429A3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201282000AMedicaid
2150437OtherPK