Provider Demographics
NPI:1508853045
Name:PROFESSIONAL ARTS PHARMACY
Entity Type:Organization
Organization Name:PROFESSIONAL ARTS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-662-4051
Mailing Address - Street 1:441 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2612
Mailing Address - Country:US
Mailing Address - Phone:765-662-1441
Mailing Address - Fax:765-651-7351
Practice Address - Street 1:330 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2600
Practice Address - Country:US
Practice Address - Phone:765-664-2247
Practice Address - Fax:765-664-2328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015280A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100296300Medicaid