Provider Demographics
NPI:1770524472
Name:WILLIAMS LTC PHARMACY, LLC
Entity type:Organization
Organization Name:WILLIAMS LTC PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF STRATEGY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CLAYBORNE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-254-2497
Mailing Address - Street 1:PO BOX 498
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0498
Mailing Address - Country:US
Mailing Address - Phone:812-254-2497
Mailing Address - Fax:812-257-2592
Practice Address - Street 1:11900 EXIT 5 PKWY
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7939
Practice Address - Country:US
Practice Address - Phone:317-889-4125
Practice Address - Fax:317-889-4134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006345A332B00000X, 332BP3500X, 3336H0001X, 3336L0003X
IL203.001778332B00000X, 332BP3500X
IL054.0185093336H0001X, 3336L0003X
OHNRP.022594950-033336H0001X, 3336L0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200446060AMedicaid
2142039OtherPK
IN200446060AMedicaid