Organization
BEACON HEALTH VENTURES INC
Active
Other names
Beacon HC Pharmacy SB
Organization subpart
No
Provider details
NPI number
Authorized official
TRUDY K WAIT (MANAGER)
(574) 647-8674
Entity
Organization
Contact information
Practice address
3355 DOUGLAS RD, SOUTH BEND, IN 46635-1779
(574) 647-8675
(574) 647-8764
Mailing address
3355 DOUGLAS RD, SOUTH BEND, IN 46635-1779
(574) 647-8675
(574) 647-8764
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
—
—
3336C0004X
Compounding Pharmacy
—
—
3336H0001X
Home Infusion Therapy Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000097412
ANTHEM PROVIDER
IN
01
—
000000107793
ANTHEM
IN
01
—
100263690A
WAIVER
IN
05
—
100301140A
—
IN
01
—
M300042869
MEDICARE PART B/IMMUNIZATIONS
IN
Enumeration date
11/17/2006
Last updated
12/09/2025
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