Provider Demographics
NPI:1902298557
Name:WITHAM MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:PAVILION POINTE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-483-3900
Mailing Address - Street 1:2705 N LEBANON ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8621
Mailing Address - Country:US
Mailing Address - Phone:765-483-3900
Mailing Address - Fax:765-483-3909
Practice Address - Street 1:2705 N LEBANON ST STE 100
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8621
Practice Address - Country:US
Practice Address - Phone:765-483-3900
Practice Address - Fax:765-483-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60006428A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147853OtherPK
IN300067193Medicaid