Provider Demographics
NPI:1477652428
Name:INDIAN RIVER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:INDIAN RIVER MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O. PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-567-4311
Mailing Address - Street 1:1000 36TH ST
Mailing Address - Street 2:RETAIL PHARMACY
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4862
Mailing Address - Country:US
Mailing Address - Phone:772-567-4311
Mailing Address - Fax:772-794-1462
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:RETAIL PHARMACY
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-567-4311
Practice Address - Fax:772-794-1462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH-89263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy