Provider Demographics
NPI:1811923543
Name:COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC
Entity type:Organization
Organization Name:COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMENTROUT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:260-463-9373
Mailing Address - Street 1:207 N TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-1325
Mailing Address - Country:US
Mailing Address - Phone:260-463-2143
Mailing Address - Fax:260-463-3790
Practice Address - Street 1:207 N TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1325
Practice Address - Country:US
Practice Address - Phone:260-463-9373
Practice Address - Fax:260-463-9370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2019-11-19
Deactivation Date:2019-04-24
Deactivation Code:
Reactivation Date:2019-11-19
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 333600000X
IN60005889A3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2027033OtherPK
151323Medicare ID - Type Unspecified