MEDICARE: MRS. JESECA MARTEL KILLEEN R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26023479A	IN
2	183500000X	Pharmacist	PH25383	MA

General Provider Information

NPI Number	:	1518252410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESECA MARTEL KILLEEN R.PH.

Provider Business Mailing Address
First Line	:	1300 E 86TH ST
Second Line	:	T-1848 STE. 35
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1997
Country	:	US
Telephone Number	:	617-461-2604
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 E 86TH ST
Second Line	:	T-1848 STE. 35
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1997
Country	:	US
Telephone Number	:	317-810-0045
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	06/20/2011

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