Healthcare Provider Details

I. General information

NPI: 1073005617
Provider Name (Legal Business Name): JULIE DIANE PELLETT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WOODLAND HILLS BLVD
FORT SCOTT KS
66701-8797
US

IV. Provider business mailing address

PO BOX 1104
FORT SCOTT KS
66701-1104
US

V. Phone/Fax

Practice location:
  • Phone: 620-223-7075
  • Fax: 620-223-7050
Mailing address:
  • Phone: 620-223-7075
  • Fax: 620-223-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-13467
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: