Provider Demographics
NPI:1285784058
Name:HOUCHENS EXPRESS PHARMACY LLC
Entity type:Organization
Organization Name:HOUCHENS EXPRESS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-661-8684
Mailing Address - Street 1:815 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47635-1123
Mailing Address - Country:US
Mailing Address - Phone:812-649-2227
Mailing Address - Fax:812-649-3253
Practice Address - Street 1:815 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-1123
Practice Address - Country:US
Practice Address - Phone:812-649-2227
Practice Address - Fax:812-649-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2024-08-23
Deactivation Date:2024-08-21
Deactivation Code:
Reactivation Date:2024-08-23
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IN60006377A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201226620AMedicaid
2145889OtherPK
IN6198680004Medicare NSC
2145889OtherPK
2145889OtherPK
ININ2030OtherMEDICARE PART B IMMUNIZATION
INFH4484616OtherDEA