# FORT WAYNE MEDICAL ONCOLOGY & HEMAT

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** FT WAYNE MED ONCOLOGY AND HEMATOLOGY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215066949
- **Authorized official:** TRACY MARAVILLA PHARMD (PHARMACY DIRECTOR)
- **Authorized official phone:** (260) 484-9660

## Contact information

- **Practice address:** 4402 E STATE BLVD, FORT WAYNE, IN 46815-6917
- **Practice address phone:** (260) 969-7846
- **Practice address fax:** (260) 483-1734
- **Mailing address:** PO BOX 15099, FORT WAYNE, IN 46885-5099

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0002X | Clinic Pharmacy | 60005894A | IN | Yes |

## Other

- **Enumeration date:** 03/06/2007
- **Last updated:** 05/03/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1560247 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |
| 05 | — | 200544860A | — | IN |