Provider Demographics
NPI:1992391338
Name:BOOTH, CHARLES R
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:BOOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 S LEONARD RD
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9705
Mailing Address - Country:US
Mailing Address - Phone:317-861-5045
Mailing Address - Fax:
Practice Address - Street 1:4935 S ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-3516
Practice Address - Country:US
Practice Address - Phone:317-791-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013981A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist