Provider Demographics
NPI:1609241629
Name:UPLAND FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:UPLAND FAMILY PHARMACY LLC
Other - Org Name:UPLAND FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-375-6136
Mailing Address - Street 1:1809 S MAIN ST STE 150
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46989-9259
Mailing Address - Country:US
Mailing Address - Phone:765-998-8072
Mailing Address - Fax:765-998-8094
Practice Address - Street 1:1809 S MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:IN
Practice Address - Zip Code:46989-9259
Practice Address - Country:US
Practice Address - Phone:765-998-8072
Practice Address - Fax:765-998-8094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60006517A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201335170AMedicaid
2155564OtherPK