=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992376644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATELYN SHELBY MCCOURT PHARMD, RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2021
-----------------------------------------------------
Last Update Date | 07/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 437 N WOLF CREEK ST
-----------------------------------------------------
City | BROOKVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45309-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-833-2174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 437 N WOLF CREEK ST
-----------------------------------------------------
City | BROOKVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45309-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-833-2174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03440705
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------