Provider Demographics
NPI:1740550334
Name:DEACONESS HOSPITAL INC
Entity type:Organization
Organization Name:DEACONESS HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FITE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-450-3780
Mailing Address - Street 1:600 MARY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1658
Mailing Address - Country:US
Mailing Address - Phone:812-450-3784
Mailing Address - Fax:812-450-3781
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1658
Practice Address - Country:US
Practice Address - Phone:812-450-3784
Practice Address - Fax:812-450-3781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336S0011X
IN60001691A3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133261OtherPK
IN201054000AMedicaid