Healthcare Provider Details

I. General information

NPI: 1164022646
Provider Name (Legal Business Name): CARLY RENEE KOWALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 5TH AVE
HAMMOND IN
46320-1002
US

IV. Provider business mailing address

1100 5TH AVE
HAMMOND IN
46320-1002
US

V. Phone/Fax

Practice location:
  • Phone: 219-473-9709
  • Fax: 219-473-9714
Mailing address:
  • Phone: 219-473-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26023877A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: