Healthcare Provider Details

I. General information

NPI: 1316602048
Provider Name (Legal Business Name): KELSEY JO LANFAIR PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELSEY JO THOMAS PHARMD

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 STATE ROAD W 46
BLOOMINGTON IN
47404
US

IV. Provider business mailing address

4444 STATE ROAD W 46
BLOOMINGTON IN
47404
US

V. Phone/Fax

Practice location:
  • Phone: 812-876-2915
  • Fax: 812-935-8445
Mailing address:
  • Phone: 812-876-2915
  • Fax: 812-935-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26028803A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: