Provider Demographics
NPI:1215066949
Name:FORT WAYNE MEDICAL ONCOLOGY & HEMAT
Entity type:Organization
Organization Name:FORT WAYNE MEDICAL ONCOLOGY & HEMAT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARAVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:260-484-9660
Mailing Address - Street 1:PO BOX 15099
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46885-5099
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4402 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6917
Practice Address - Country:US
Practice Address - Phone:260-969-7846
Practice Address - Fax:260-483-1734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60005894A3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200544860AMedicaid
1560247OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN200544860AMedicaid