Provider Demographics
NPI:1316379894
Name:NELSON, KEVIN R (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PINE LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3027
Mailing Address - Country:US
Mailing Address - Phone:219-325-3152
Mailing Address - Fax:
Practice Address - Street 1:55 PINE LAKE AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3027
Practice Address - Country:US
Practice Address - Phone:219-325-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024735A183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist