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General NPI Number Information
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NPI Number | 1659080893
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Entity Type | Individual
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Provider Name | BETTY JEAN KETCHMARK PHARMD RP
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Gender | Female
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Dates
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Enumeration Date | 11/16/2022
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Last Update Date | 11/16/2022
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Provider Practice Location Address
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Address Line | 8637 S 99 CIRCLE
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City | LAVISTA
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State | NE
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Zip | 68128-7010
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Country | US
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Telephone | 402-639-0965
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Fax |
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Provider Business Mailing Address
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Address Line | 8637 S 99 CIRCLE
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City | LAVISTA
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State | NE
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Zip | 68128-7010
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Country | US
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Telephone | 402-639-0965
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | P7739
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 10348
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License Number State | NE
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