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Organization
FORT WAYNE MEDICAL ONCOLOGY & HEMAT
Active
Organization
FORT WAYNE MEDICAL ONCOLOGY & HEMAT
Active
Other names
FT WAYNE MED ONCOLOGY AND HEMATOLOGY
Organization subpart
No
Provider details
NPI number
Authorized official
TRACY MARAVILLA PHARMD (PHARMACY DIRECTOR)
(260) 484-9660
Entity
Organization
Contact information
Practice address
4402 E STATE BLVD, FORT WAYNE, IN 46815-6917
(260) 969-7846
(260) 483-1734
Mailing address
PO BOX 15099, FORT WAYNE, IN 46885-5099
Taxonomy
Speciality
Code
Description
License number
State
3336C0002X
Clinic Pharmacy
Primary
60005894A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1560247
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
200544860A
—
IN
Enumeration date
03/06/2007
Last updated
05/03/2010
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