Provider Demographics
NPI:1912090440
Name:NEIGHBORCARE OF INDIANA, LLC
Entity Type:Organization
Organization Name:NEIGHBORCARE OF INDIANA, LLC
Other - Org Name:OMNICARE OF FT. WAYNE #48246
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3402 CONGRESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:FT. WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808
Practice Address - Country:US
Practice Address - Phone:260-484-7366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
IN60005446A3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100293370AMedicaid
1531171OtherNCPDP
IN100293370AMedicaid