Provider Demographics
NPI:1174091557
Name:RUBICON DTP, LLC
Entity type:Organization
Organization Name:RUBICON DTP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT- PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BURAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:317-552-1100
Mailing Address - Street 1:5175 W 73RD STREET
Mailing Address - Street 2:B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278
Mailing Address - Country:US
Mailing Address - Phone:833-200-2010
Mailing Address - Fax:317-552-1101
Practice Address - Street 1:5751 W 73RD ST # A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1741
Practice Address - Country:US
Practice Address - Phone:317-524-1515
Practice Address - Fax:844-325-7228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1569776OtherNCPDP
1407877467OtherNPI
IN20080595AMedicaid
IN20080595AMedicaid