Provider Demographics
NPI:1457587669
Name:FAIRMEADOWS PHARMACY
Entity type:Organization
Organization Name:FAIRMEADOWS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:ZURAWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:219-836-8700
Mailing Address - Street 1:800 MACARTHUR BLVD
Mailing Address - Street 2:STE 29
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2917
Mailing Address - Country:US
Mailing Address - Phone:219-836-8700
Mailing Address - Fax:219-836-7639
Practice Address - Street 1:800 MACARTHUR BLVD STE 29
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2917
Practice Address - Country:US
Practice Address - Phone:219-836-8700
Practice Address - Fax:219-836-7639
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRMEADOWS PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60002227A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100298770AMedicaid
IN1515038OtherNCPDP
IL=========001Medicaid
IL=========001Medicaid