Provider Demographics
NPI:1346843018
Name:HAMILTON, RILEY J
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:J
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 VALUE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-4048
Mailing Address - Country:US
Mailing Address - Phone:260-481-1110
Mailing Address - Fax:260-481-1101
Practice Address - Street 1:5110 VALUE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-4048
Practice Address - Country:US
Practice Address - Phone:260-481-1110
Practice Address - Fax:260-481-1101
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67020399A183700000X
IN45022954A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician