Provider Demographics
NPI:1114044039
Name:KETCHUM, DANITA L (RPH)
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:L
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 S MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5321
Mailing Address - Country:US
Mailing Address - Phone:607-273-3231
Mailing Address - Fax:607-273-4825
Practice Address - Street 1:744 S MEADOW ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5321
Practice Address - Country:US
Practice Address - Phone:607-273-3231
Practice Address - Fax:607-273-4825
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist