Provider Demographics
NPI:1770006173
Name:PLYMOUTH TOWNE CARE PHARMACY INC
Entity Type:Organization
Organization Name:PLYMOUTH TOWNE CARE PHARMACY INC
Other - Org Name:PEOPLES DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-936-3167
Mailing Address - Street 1:301 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1735
Mailing Address - Country:US
Mailing Address - Phone:574-936-3167
Mailing Address - Fax:574-936-6155
Practice Address - Street 1:301 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1735
Practice Address - Country:US
Practice Address - Phone:574-936-3167
Practice Address - Fax:574-936-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006496A333600000X
WI1929-433336L0003X
IL0540204043336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100309590BMedicaid
2170772OtherPK