Provider Demographics
NPI:1720126295
Name:DEKALB MEMORIAL PHARMACARE LLC
Entity Type:Organization
Organization Name:DEKALB MEMORIAL PHARMACARE LLC
Other - Org Name:DEKALB HEALTH PHARMACARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:POLKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-925-4600
Mailing Address - Street 1:1314 E 7TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-2533
Mailing Address - Country:US
Mailing Address - Phone:260-925-8000
Mailing Address - Fax:260-925-9500
Practice Address - Street 1:1314 E 7TH ST STE 104
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2533
Practice Address - Country:US
Practice Address - Phone:260-925-8000
Practice Address - Fax:260-925-9500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
IN60006238A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129458OtherPK
IN10029410AMedicaid
6502700001Medicare NSC