Healthcare Provider Details

I. General information

NPI: 1851674543
Provider Name (Legal Business Name): ELKANAH ISRAEL KINDSETH PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 LIBERTY RD
NORMAL IL
61761-1311
US

IV. Provider business mailing address

1114 LIBERTY RD
NORMAL IL
61761-1311
US

V. Phone/Fax

Practice location:
  • Phone: 309-830-6687
  • Fax: 417-532-9743
Mailing address:
  • Phone: 309-830-6687
  • Fax: 417-532-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2011023692
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: