Provider Demographics
NPI:1659485621
Name:JOHN OF LYNNS TERRE HAUTE PHCY LLC
Entity Type:Organization
Organization Name:JOHN OF LYNNS TERRE HAUTE PHCY LLC
Other - Org Name:TERRE HAUTE PRESCRIPTION SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-232-9646
Mailing Address - Street 1:PO BOX 10998
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47801-0998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3020 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3902
Practice Address - Country:US
Practice Address - Phone:812-232-9646
Practice Address - Fax:812-232-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60005407A333600000X
3336C0003X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1003022804AMedicaid
1500049OtherOTHER ID NUMBER-COMMERCIAL NUMBER