Healthcare Provider Details

I. General information

NPI: 1124691456
Provider Name (Legal Business Name): KELSEY CUPP PHARMD, RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 CHESTER BLVD
RICHMOND IN
47374-1105
US

IV. Provider business mailing address

17196 GOOSE HEAVEN RD
CAMBRIDGE CITY IN
47327-9704
US

V. Phone/Fax

Practice location:
  • Phone: 765-939-4400
  • Fax:
Mailing address:
  • Phone: 765-541-9765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number26029334A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: