Provider Demographics
NPI:1548590847
Name:GOSHEN HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:GOSHEN HOSPITAL ASSOCIATION INC
Other - Org Name:GOSHEN CANCER CENTER OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-364-2651
Mailing Address - Street 1:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0139
Mailing Address - Country:US
Mailing Address - Phone:574-364-2803
Mailing Address - Fax:574-364-2804
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-364-2803
Practice Address - Fax:574-364-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60001389A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122794OtherPK
IN200984460AMedicaid