Provider Demographics
NPI:1851177877
Name:STARK, AUSTIN TANNER (PHARMD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TANNER
Last Name:STARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N MERIDIAN ST APT 316
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-7703
Mailing Address - Country:US
Mailing Address - Phone:262-955-0334
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD # B222
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:262-955-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030434A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist