Organization
CAREFIRST OF FORTWAYNE INC
Active
Other names
Advanced Healthcare
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL EDWARD JOHNSON RRT (PRESIDENT)
(260) 373-1600
Entity
Organization
Contact information
Practice address
718 N WAYNE ST, ANGOLA, IN 46703-1006
(260) 624-3093
Mailing address
3204 CONGRESSIONAL PKWY, FORT WAYNE, IN 46808-4417
(260) 373-1600
(260) 373-1601
Taxonomy
Speciality
Code
Description
License number
State
332BX2000X
Oxygen Equipment & Supplies (DME)
Primary
69000127A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
69000127A
PHARMACY LICENSE
IN
Enumeration date
08/06/2007
Last updated
11/15/2007
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