Provider Demographics
NPI:1760570030
Name:PAULS PHARMACY INC
Entity Type:Organization
Organization Name:PAULS PHARMACY INC
Other - Org Name:PAULS PHARMACY EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:SYLVARIUS
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-425-4364
Mailing Address - Street 1:1150 S GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-6804
Mailing Address - Country:US
Mailing Address - Phone:812-962-3500
Mailing Address - Fax:812-962-3510
Practice Address - Street 1:1225 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-6807
Practice Address - Country:US
Practice Address - Phone:812-962-3500
Practice Address - Fax:812-962-3510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAULS PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60005616A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200337390Medicaid
IN0234080002Medicare NSC