Provider Demographics
NPI:1740272053
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 1:710 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-1045
Mailing Address - Country:US
Mailing Address - Phone:765-628-3446
Mailing Address - Fax:765-628-2639
Practice Address - Street 1:710 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-1045
Practice Address - Country:US
Practice Address - Phone:765-628-3446
Practice Address - Fax:765-628-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60005692A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200382710Medicaid
2024592OtherPK