Provider Demographics
NPI:1801171970
Name:DEBOER, JOHN R (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:DEBOER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6204 SCHOOLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SPEEDWAY
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3243
Mailing Address - Country:US
Mailing Address - Phone:317-298-3465
Mailing Address - Fax:
Practice Address - Street 1:1516 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-1791
Practice Address - Country:US
Practice Address - Phone:317-838-9187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26091876A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist