Healthcare Provider Details

I. General information

NPI: 1104427947
Provider Name (Legal Business Name): KATRINA HEGDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 CRAIG AVE
GREENDALE IN
47025-7529
US

IV. Provider business mailing address

432 CRAIG AVE
GREENDALE IN
47025-7529
US

V. Phone/Fax

Practice location:
  • Phone: 812-537-0855
  • Fax: 812-537-5641
Mailing address:
  • Phone: 812-537-0855
  • Fax: 812-537-5641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number020857
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03438589
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026942A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: