Provider Demographics
NPI:1023268703
Name:BLUE RIVER PHARMACY INC
Entity type:Organization
Organization Name:BLUE RIVER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:317-286-3506
Mailing Address - Street 1:680 E 56TH ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7776
Mailing Address - Country:US
Mailing Address - Phone:317-286-3506
Mailing Address - Fax:877-412-1704
Practice Address - Street 1:26 S GREEN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1251
Practice Address - Country:US
Practice Address - Phone:317-286-3506
Practice Address - Fax:317-350-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X, 332BX2000X, 333600000X, 3336C0004X
IN60006168A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200914920AMedicaid
2117408OtherPK
IN200914920AMedicaid