Provider Demographics
NPI:1497805717
Name:VILLAGE DRUG STORE
Entity Type:Organization
Organization Name:VILLAGE DRUG STORE
Other - Org Name:VILLAGE DRUG STORE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:PETRICEK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:765-364-0324
Mailing Address - Street 1:PO BOX 661
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-0661
Mailing Address - Country:US
Mailing Address - Phone:765-364-0324
Mailing Address - Fax:765-364-0325
Practice Address - Street 1:1313 HOMEWOOD DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3341
Practice Address - Country:US
Practice Address - Phone:765-364-0324
Practice Address - Fax:765-364-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60002857A3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1520887OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN100294590AMedicaid
0328190001Medicare NSC