Provider Demographics
NPI:1902900954
Name:INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL INC
Other - Org Name:IU HEALTH PAVILION COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-751-2795
Mailing Address - Street 1:1633 N CAPITOL AVE
Mailing Address - Street 2:SUITE 438
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1261
Mailing Address - Country:US
Mailing Address - Phone:317-963-9730
Mailing Address - Fax:317-963-5003
Practice Address - Street 1:2401 W UNIVERSITY AVE # OMP1635
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-747-8461
Practice Address - Fax:765-747-8472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60004092A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100295190Medicaid
1528732OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN0797520011Medicare NSC