Provider Demographics
NPI:1144357328
Name:THE SOUTH BEND CLINIC PHARMACY
Entity type:Organization
Organization Name:THE SOUTH BEND CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR PHARMACY
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-239-1461
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9295
Mailing Address - Fax:574-239-1554
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617
Practice Address - Country:US
Practice Address - Phone:574-237-9295
Practice Address - Fax:574-239-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60004874A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1507221OtherNABP OR NCPDP
IN100300930Medicaid