Provider Demographics
NPI:1649318080
Name:INDIANA MOTHERS' MILK BANK, INC.
Entity type:Organization
Organization Name:INDIANA MOTHERS' MILK BANK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:317-329-7147
Mailing Address - Street 1:6820 PARKDALE PL STE 109
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4699
Mailing Address - Country:US
Mailing Address - Phone:317-328-7147
Mailing Address - Fax:317-329-7151
Practice Address - Street 1:6820 PARKDALE PL STE 109
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4699
Practice Address - Country:US
Practice Address - Phone:317-328-7147
Practice Address - Fax:317-329-7151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid