Healthcare Provider Details

I. General information

NPI: 1720874613
Provider Name (Legal Business Name): JENITA IKELJIC PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 CALUMET AVE
VALPARAISO IN
46383-2703
US

IV. Provider business mailing address

1903 CALUMET AVE
VALPARAISO IN
46383-2703
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-6172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26030590A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: