Provider Demographics
NPI:1033978762
Name:KOCH, KAITLYN TAYLOR (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:TAYLOR
Last Name:KOCH
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6468 W 113TH CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4274
Mailing Address - Country:US
Mailing Address - Phone:219-333-1166
Mailing Address - Fax:
Practice Address - Street 1:575 STADIUM MALL DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2091
Practice Address - Country:US
Practice Address - Phone:765-494-1374
Practice Address - Fax:765-496-6094
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030449A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist