Provider Demographics
NPI:1902102080
Name:HEROD, JOHN (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HEROD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 N RUSTIC CT
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-9645
Mailing Address - Country:US
Mailing Address - Phone:219-324-5808
Mailing Address - Fax:
Practice Address - Street 1:525 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3833
Practice Address - Country:US
Practice Address - Phone:219-326-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020069A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26020069AOtherINDIANA PHARMACIST LICENSE