Healthcare Provider Details

I. General information

NPI: 1548650294
Provider Name (Legal Business Name): RACHEL POPHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4174 WESTPORT RD
LOUISVILLE KY
40207-2735
US

IV. Provider business mailing address

1408 HEPBURN AVE
LOUISVILLE KY
40204-1616
US

V. Phone/Fax

Practice location:
  • Phone: 502-992-1040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT00029606
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: