Provider Demographics
NPI:1487944294
Name:GEORGE'S FAMILY PHARMACY, INC.
Entity type:Organization
Organization Name:GEORGE'S FAMILY PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-265-4699
Mailing Address - Street 1:326 S. WASHINGTON ST. SUITE 22
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:IN
Mailing Address - Zip Code:47042
Mailing Address - Country:US
Mailing Address - Phone:812-689-0200
Mailing Address - Fax:812-689-0201
Practice Address - Street 1:326 S. WASHINGTON ST. SUITE 22
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:IN
Practice Address - Zip Code:47042
Practice Address - Country:US
Practice Address - Phone:812-689-0200
Practice Address - Fax:812-689-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IN60006249A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1563306OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN300079697Medicaid
IN100295890AMedicaid
1563306OtherNCPDP PROVIDER IDENTIFICATION NUMBER