Provider Demographics
NPI:1942428420
Name:PARKVIEW HOSPITAL, INC.
Entity Type:Organization
Organization Name:PARKVIEW HOSPITAL, INC.
Other - Org Name:MEDICAL PARK 11 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-266-9313
Mailing Address - Street 1:11104 PARKVIEW CIRCLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1704
Mailing Address - Country:US
Mailing Address - Phone:260-266-4545
Mailing Address - Fax:260-266-4549
Practice Address - Street 1:11104 PARKVIEW CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1704
Practice Address - Country:US
Practice Address - Phone:260-266-4545
Practice Address - Fax:260-266-4549
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARKVIEW HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2019-07-16
Deactivation Date:2019-04-24
Deactivation Code:
Reactivation Date:2019-07-16
Provider Licenses
StateLicense IDTaxonomies
IN60000294A3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1536119OtherNCPDP
IN100470980AMedicaid