Provider Demographics
NPI:1285292722
Name:MEMORIAL HOSPITAL OF SOUTH BEND - TEAM PHARMACY
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL OF SOUTH BEND - TEAM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3460
Mailing Address - Street 1:100 NAVARRE PL STE 1150
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1156
Mailing Address - Country:US
Mailing Address - Phone:574-647-3534
Mailing Address - Fax:574-647-6767
Practice Address - Street 1:100 NAVARRE PL STE 1150
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1156
Practice Address - Country:US
Practice Address - Phone:574-647-3534
Practice Address - Fax:574-647-6767
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL OF SOUTH BEND, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-30
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300029964Medicaid