Provider Demographics
NPI:1619389095
Name:PURVIS, JOHN PHILLIP
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:PURVIS
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 1:1227 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6309 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1425
Practice Address - Country:US
Practice Address - Phone:260-497-1010
Practice Address - Fax:260-497-1065
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015107A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy