Provider Demographics
NPI:1780788927
Name:CLOVERDALE DRUGS, INC
Entity type:Organization
Organization Name:CLOVERDALE DRUGS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNEDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-795-4100
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:IN
Mailing Address - Zip Code:46120-0357
Mailing Address - Country:US
Mailing Address - Phone:765-795-4100
Mailing Address - Fax:765-795-5310
Practice Address - Street 1:900 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:IN
Practice Address - Zip Code:46120-8506
Practice Address - Country:US
Practice Address - Phone:765-795-4100
Practice Address - Fax:765-795-5310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100300610Medicaid
1509934OtherNABP
1509934OtherNABP