Provider Demographics
NPI:1275179772
Name:PRATER, CARLY RENEE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:RENEE
Last Name:PRATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8637 KNOLLWAY CT
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3581
Mailing Address - Country:US
Mailing Address - Phone:317-509-0419
Mailing Address - Fax:
Practice Address - Street 1:9835 FALL CREEK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4802
Practice Address - Country:US
Practice Address - Phone:317-577-3486
Practice Address - Fax:317-577-3487
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022537A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist