Healthcare Provider Details

I. General information

NPI: 1740631688
Provider Name (Legal Business Name): KATHLEEN CONDO PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N DIXON RD
KOKOMO IN
46901-4131
US

IV. Provider business mailing address

4109 HONEY CREEK BLVD
RUSSIAVILLE IN
46979-9155
US

V. Phone/Fax

Practice location:
  • Phone: 765-457-1191
  • Fax: 765-868-3184
Mailing address:
  • Phone: 765-883-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26018620A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: