Provider Demographics
NPI:1295727501
Name:HERBST APOTHECARY INC
Entity type:Organization
Organization Name:HERBST APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:765-457-1191
Mailing Address - Street 1:300 E SOUTHWAY BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3678
Mailing Address - Country:US
Mailing Address - Phone:765-455-5418
Mailing Address - Fax:765-455-5724
Practice Address - Street 1:300 E SOUTHWAY BLVD STE E
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3678
Practice Address - Country:US
Practice Address - Phone:765-455-5418
Practice Address - Fax:765-455-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60004199A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100297370Medicaid
2027246OtherPK