Provider Demographics
NPI:1790762938
Name:HOSTETLER'S STORE INC
Entity Type:Organization
Organization Name:HOSTETLER'S STORE INC
Other - Org Name:HOSTETLER'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOSTETLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-768-4882
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-0155
Mailing Address - Country:US
Mailing Address - Phone:260-768-4882
Mailing Address - Fax:260-768-7238
Practice Address - Street 1:CORNER MAIN AND MORTON ST
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565
Practice Address - Country:US
Practice Address - Phone:260-768-4882
Practice Address - Fax:260-768-7238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60003002A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1522108OtherNCPDP (NABP) #
IN100298300AMedicaid
IN1522108OtherNCPDP (NABP) #